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Sample records for address patient safety

  1. A region addresses patient safety.

    PubMed

    Feinstein, Karen Wolk; Grunden, Naida; Harrison, Edward I

    2002-06-01

    The Pittsburgh Regional Healthcare Initiative (PRHI) is a coalition of 35 hospitals, 4 major insurers, more than 30 major and small-business health care purchasers, dozens of corporate and civic leaders, organized labor, and partnerships with state and federal government all working together to deliver perfect patient care throughout Southwestern Pennsylvania. PRHI believes that in pursuing perfection, many of the challenges facing today's health care delivery system (eg, waste and error in the delivery of care, rising costs, frustration and shortage among clinicians and workers, financial distress, overcapacity, and lack of access to care) will be addressed. PRHI has identified patient safety (nosocomial infections and medication errors) and 5 clinical areas (obstetrics, orthopedic surgery, cardiac surgery, depression, and diabetes) as ideal starting points. In each of these areas of work, PRHI partners have assembled multifacility/multidisciplinary groups charged with defining perfection, establishing region-wide reporting systems, and devising and implementing recommended improvement strategies and interventions. Many design and conceptual elements of the PRHI strategy are adapted from the Toyota Production System and its Pittsburgh derivative, the Alcoa Business System. PRHI is in the proof-of-concept phase of development.

  2. Addressing patient safety through the use of 'criteria of acceptability' for medical radiation equipment.

    PubMed

    Gilley, Debbie Bray; Holmberg, Ola

    2013-02-01

    Patient safety should be considered in the use of ionising radiation equipment in medicine. The International Atomic Energy Agency (IAEA) establishes standards of safety and provides for the application of these standards, also in the area of medical use of radiation. Equipment acceptability, as it relates to radiation in medicine, is the need to satisfy the requirements or standards prior to the use of the device in patient imaging or treatment. Through IAEA activities in establishing and developing Safety Standards, Safety Reports and recommendations to regulatory authorities and end-users, it encourages the adoption of acceptability criteria that are relevant to the medical equipment and its use.

  3. Safety Matters: How One District Addressed Safety Concerns

    ERIC Educational Resources Information Center

    Heinen, Ethan; Webb-Dempsey, Jaci; Moore, Lucas; McClellan, Craig; Friebel, Carl

    2007-01-01

    As a result of Columbine and other events, states and districts across the United States have responded with vigor to a call for a renewed focus on school safety. This paper examined one such effort undertaken by Harrison County Public Schools, located in West Virginia. The district received federal funding for surveillance equipment used to…

  4. [Patient safety: Glossary].

    PubMed

    Sabio Paz, Verónica; Panattieri, Néstor D; Cristina Godio, Farmacéutica; Ratto, María E; Arpí, Lucrecia; Dackiewicz, Nora

    2015-10-01

    Patient safety and quality of care has become a challenge for health systems. Health care is an increasingly complex and risky activity, as it represents a combination of human, technological and organizational processes. It is necessary, therefore, to take effective actions to reduce the adverse events and mitigate its impact. This glossary is a local adaptation of key terms and concepts from the international bibliographic sources. The aim is providing a common language for assessing patient safety processes and compare them.

  5. Addressing health literacy in patient decision aids

    PubMed Central

    2013-01-01

    Background Effective use of a patient decision aid (PtDA) can be affected by the user’s health literacy and the PtDA’s characteristics. Systematic reviews of the relevant literature can guide PtDA developers to attend to the health literacy needs of patients. The reviews reported here aimed to assess: 1. a) the effects of health literacy / numeracy on selected decision-making outcomes, and b) the effects of interventions designed to mitigate the influence of lower health literacy on decision-making outcomes, and 2. the extent to which existing PtDAs a) account for health literacy, and b) are tested in lower health literacy populations. Methods We reviewed literature for evidence relevant to these two aims. When high-quality systematic reviews existed, we summarized their evidence. When reviews were unavailable, we conducted our own systematic reviews. Results Aim 1: In an existing systematic review of PtDA trials, lower health literacy was associated with lower patient health knowledge (14 of 16 eligible studies). Fourteen studies reported practical design strategies to improve knowledge for lower health literacy patients. In our own systematic review, no studies reported on values clarity per se, but in 2 lower health literacy was related to higher decisional uncertainty and regret. Lower health literacy was associated with less desire for involvement in 3 studies, less question-asking in 2, and less patient-centered communication in 4 studies; its effects on other measures of patient involvement were mixed. Only one study assessed the effects of a health literacy intervention on outcomes; it showed that using video to improve the salience of health states reduced decisional uncertainty. Aim 2: In our review of 97 trials, only 3 PtDAs overtly addressed the needs of lower health literacy users. In 90% of trials, user health literacy and readability of the PtDA were not reported. However, increases in knowledge and informed choice were reported in those studies

  6. Use of feedback control to address flight safety issues

    NASA Astrophysics Data System (ADS)

    Ganguli, Subhabrata

    This thesis addresses three control problems related to flight safety. The first problem relates to the scope of improvement in performance of conventional flight control laws. In particular, aircraft longitudinal axis control based on the Total Energy Control System (TECS) is studied. The research draws attention to a potentially sluggish and undesirable aircraft response when the engine dynamics is slow (typically the case). The proposed design method uses a theoretically well-developed modern design method based on Hinfinity optimization to improve the aircraft dynamic behavior in spite of slow engine characteristics. At the same time, the proposed design method achieves other desirable performance goals such as insensitivity to sensor noise and wind gust rejection: all addressed in one unified framework. The second problem is based on a system level analysis of control structure hierarchy for aircraft flight control. The objective of the analysis problem is to translate outer-loop stability and performance specifications into a comprehensive inner-loop metric. The prime motivation is to make the flight control design process more systematic and the system-integration reliable and independent of design methodology. The analysis problem is posed within the robust control analysis framework. Structured singular value techniques and free controller parameterization ideas are used to impose a hierarchical structure for flight control architecture. The third problem involves development and demonstration of a new reconfiguration strategy in the flight control architecture that has the potential of improving flight safety while keeping cost and complexity low. This research proposes a fault tolerant feature based on active robust reconfiguration. The fault tolerant control problem is formulated in the Linear Parameter Varying (LPV) design framework. A prime advantage of this approach is that the synthesis results in a single nonlinear controller (as opposed to a bank

  7. Systems Thinking and Patient Safety

    DTIC Science & Technology

    2005-01-01

    1 Prologue Systems Thinking and Patient Safety Paul M. Schyve Patient safety is a prominent theme in health care delivery today. This should...been “unenlightened,” to say the least; we would not have been able to apply systems thinking to patient safety. Even today, preventable patient...in the minds of many, to be met with blame and punishment. But systems thinking is now ubiquitous in health care—due, in large measure, to its

  8. Implementing national patient safety alerts.

    PubMed

    Moore, Sally; Taylor, Natalie; Lawton, Rebecca; Slater, Beverley

    National patient safety alerts are sometimes difficult to implement in an effective way. All trusts have to declare compliance with alerts as part of a three-step process to improve patient safety. This article discusses an alternative way of implementing national patient safety alerts and describes how behaviour-change methods can be used to successfully implement lasting changes in practice at ward or departmental level.

  9. The Value of Addressing Patient Preferences.

    PubMed

    Allen, Jeff D; Stewart, Mark D; Roberts, Samantha A; Sigal, Ellen V

    2017-02-01

    Recent scientific progress is, in some cases, leading to transformative new medicines for diseases that previously had marginal or even no treatment options. This offers great promise for people affected by these diseases, but it has also placed stress on the health care system in terms of the growing cost associated with some new interventions. Effort has been taken to create tools to help patients and health care providers assess the value of new medical innovations. These tools may also provide the basis for assessing the price associated with new medical products. Given the growing expenditures in health care, value frameworks present an opportunity to evaluate new therapeutic options in the context of other treatments and potentially lead to a more economically sustainable health care system. In summary, the contribution to meaningful improvements in health outcomes is the primary focus of any assessment of the value of a new intervention. A component of such evaluations, however, should factor in timely access to new products that address an unmet medical need, as well as the magnitude of that beneficial impact. To achieve these goals, value assessment tools should allow for flexibility in clinical end points and trial designs, incorporate patient preferences, and continually evolve as new evidence, practice patterns, and medical progress advance.

  10. Patient Safety: Do Your Homework

    MedlinePlus

    American Society of Plastic Surgeons Home Cosmetic Reconstructive Before & After Photos Find A Surgeon Patient Safety News Patients of Courage About ASPS Menu More Call for a nearby plastic surgeon you can trust | 1-800-514-5058 ...

  11. [Risk management and patient safety].

    PubMed

    Lessing, C

    2009-06-01

    Risk management and patient safety are of indisputable importance for the quality of health care. At the same time they confront all professional groups in the health system with high demands. The Action Alliance for Patient Safety inc. wants to demonstrate ways in which measures for avoiding errors and improving safety can reach the healthcare practice. Interdisciplinary cooperation and the availability of mutually developed materials are the maxims of the work of the society.

  12. Assessing Rural Coalitions That Address Safety and Health Issues

    ERIC Educational Resources Information Center

    Burgus, Shari; Schwab, Charles; Shelley, Mack

    2012-01-01

    Community coalitions can help national organizations meet their objectives. Farm Safety 4 Just Kids depends on coalitions of local people to deliver farm safety and health educational programs to children and their families. These coalitions are called chapters. An evaluation was developed to identify individual coalition's strengths and…

  13. Developing patient safety in dentistry.

    PubMed

    Pemberton, M N

    2014-10-01

    Patient safety has always been important and is a source of public concern. Recent high profile scandals and subsequent reports, such as the Francis report into the failings at Mid Staffordshire, have raised those concerns even higher. Mortality and significant morbidity associated with the practice of medicine has led to many strategies to help improve patient safety, however, with its lack of associated mortality and lower associated morbidity, dentistry has been slower at systematically considering how patient safety can be improved. Recently, several organisations, researchers and clinicians have discussed the need for a patient safety culture in dentistry. Strategies are available to help improve patient safety in healthcare and deserve further consideration in dentistry.

  14. National Patient Safety Foundation

    MedlinePlus

    ... ASPPS Members e-News Archive Current Awareness Alert BMJ Q&S for ASPPS Members ASPPS Member News Member ... Stand Up e-News Archive Current Awareness Alert BMJ Quality & Safety Resource Guides PLS Webcast Archives Stand ...

  15. Physician accountability, patient safety and patient compensation.

    PubMed

    Gray, John E

    2006-01-01

    In Canada, the response to adverse medical events follows one or more of three main paths: patient safety, physician accountability and patient compensation. While their goals differ, each of these responses serves a valuable function. There are however competing imperatives inherent in each response, particularly in terms of information disclosure: Effective patient safety depends on the full and protected disclosure of all information relevant to an adverse event and requires a "no blame" environment. While natural justice demands that a physician be held accountable for his actions, the doctor should be accorded the right of due process and be judged against an established standard of care. This is necessarily a fault-finding activity. Patient compensation meets both accountability demands and the social justice imperatives of supporting a patient injured through physician negligence. The most effective approach is one that achieves balance between competing imperatives. With clear information disclosure rules, patient safety, physician accountability and patient compensation can operate synergistically.

  16. Addressing the clinical needs of problem drug user patients

    PubMed Central

    Krupski, Antoinette; West, Imara I.; Graves, Meredith C.; Atkins, David C.; Maynard, Charles; Bumgardner, Kristin; Donovan, Dennis; Ries, Richard; Roy-Byrne, Peter

    2016-01-01

    Introduction Illicit drug use is a serious public health problem associated with significant co-occurring medical disorders, mental disorders, and social problems. Yet most individuals with drug use disorders have never been treated, though they often seek medical treatment in primary care. The purpose of the present study was to examine baseline characteristics of persons presenting in primary care across a range of problem drug use severity to identify their clinical needs. Methods We examined socio-demographic characteristics, medical and psychiatric comorbidities, drug use severity, social and legal problems, and service utilization for 868 patients with drug problems recruited from primary care clinics in a safety-net medical setting. Based on Drug Abuse Screening Test (DAST-10) results, individuals were categorized as having low, intermediate, or substantial/severe drug use severity. Results Patients with substantial/severe drug use severity had serious drug use (opiates, stimulants, sedatives, intravenous drug use), high levels of homelessness (50%), psychiatric comorbidity (69%), arrests for serious crimes (24%), and frequent use of expensive emergency department and inpatient hospitals. Patients with low drug use severity were primarily users of marijuana with little reported use of other drugs, less psychiatric co-morbidity, and more stable lifestyles. Patients with intermediate drug use severity fell in-between the substantial/severe and low drug use severity subgroups on most variables. Conclusions Patients with highest drug use severity are likely to require specialized psychiatric and substance abuse care in addition to ongoing medical care that is equipped to address the consequences of severe/substantial drug use including intravenous drug use. Because of their milder symptoms, patients with low drug use severity may benefit from a collaborative care model that integrates psychiatric and substance abuse care in the primary care setting. Patients

  17. Creating effective leadership for improving patient safety.

    PubMed

    Mohr, Julie J; Abelson, Herbert T; Barach, Paul

    2002-01-01

    Leadership has emerged as a key theme in the rapidly growing movement to improve patient safety. Leading an organization that is committed to providing safer care requires overcoming the common traps in thinking about error, such as blaming individuals, ignoring the underlying systems factors, and blaming the bureaucracy of the organization. Leaders must address the system issues that are at work within their organizations to allow individual and organizational learning to occur.

  18. Patient safety: honoring advanced directives.

    PubMed

    Tice, Martha A

    2007-02-01

    Healthcare providers typically think of patient safety in the context of preventing iatrogenic injury. Prevention of falls and medication or treatment errors is the typical focus of adverse event analyses. If healthcare providers are committed to honoring the wishes of patients, then perhaps failures to honor advanced directives should be viewed as reportable medical errors.

  19. [Patient safety in management contracts].

    PubMed

    Campillo-Artero, C

    2012-01-01

    Patient safety is becoming commonplace in management contracts. Since our experience in patient safety still falls short of other clinical areas, it is advisable to review some of its characteristics in order to improve its inclusion in these contracts. In this paper opinions and recommendations concerning the design and review of contractual clauses on safety are given, as well as reflections drawn from methodological papers and informal opinions of clinicians, who are most familiar with the nuances of safe and unsafe practices. After reviewing some features of these contracts, criteria for prioritizing and including safety objectives and activities in them, and key points for their evaluation are described. The need to replace isolated activities by systemic and multifaceted ones is emphasized. Errors, limitations and improvement opportunities observed when contracts are linked to indicators, information and adverse event reporting systems are analysed. Finally, the influence of the rules of the game, and clinicians behaviour are emphasised.

  20. Information technologies and patient safety.

    PubMed

    Ellner, Scott J; Joyner, Paul W

    2012-02-01

    Advances in health information technology provide significant opportunities for improvements in surgical patient safety. The adoption and use of electronic health records can enhance communication along the surgical spectrum of care. Bar coding and radiofrequency identification technology are strategies to prevent retained surgical sponges and for tracking the operating room supply chain. Computerized intraoperative monitoring systems can improve the performance of the operating room team. Automated data registries collect patient information to be analyzed and used for surgical quality improvement.

  1. Patient safety: mindful, meaningful, and fulfilling.

    PubMed

    Winokur, Steven C; Beauregard, Kay J

    2005-01-01

    Five years after the landmark report of the Institute of Medicine To Err Is Human (Kohn, Corrigan, and Donaldson 2000), many are asking, "Is U.S. healthcare safer?" A number of articles addressing this question have been written, interviews with nationally recognized patient safety leaders have been published, and governing boards of many healthcare organizations are examining reports of care provided by their institutions. Robert M. Wachter, writing in the November 2004 issue of Health Affairs, concludes that, "At this point, I would give our efforts an overall grade of C+, with striking areas of progress tempered by clear opportunities for improvement." We describe in this article the pursuit of a culture of safety at William Beaumont Hospital in Royal Oak, Michigan. Our experience has offered us the opportunity to ponder a number of key questions: How does leadership guide an organization toward a culture of safety? Does culture truly drive behavior, or is it really the reverse? How can a culture of safety be measured or observed? What levels of resources and commitment are required for success? Is safety all about systems and processes, or are core values also involved? What role does the patient play in ensuring safe care? We attempt to offer guidance, and share lessons learned, for each of these important questions.

  2. 76 FR 7853 - Patient Safety Organizations: Voluntary Delisting From Oregon Patient Safety Commission

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-11

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Delisting From Oregon Patient Safety Commission AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice of delisting. SUMMARY: Oregon Patient Safety Commission: AHRQ has accepted...

  3. 76 FR 9350 - Patient Safety Organizations: Voluntary Delisting From Rocky Mountain Patient Safety Organization

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-17

    ... Delisting From Rocky Mountain Patient Safety Organization AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice of Delisting. SUMMARY: Rocky Mountain Patient Safety Organization: AHRQ has accepted a notification of voluntary relinquishment from Rocky Mountain Patient Safety Organization,...

  4. 78 FR 40146 - Patient Safety Organizations: Voluntary Relinquishment From Northern Metropolitan Patient Safety...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-07-03

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Relinquishment From Northern Metropolitan Patient Safety Institute AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice of Delisting. SUMMARY: The Patient Safety and Quality Improvement...

  5. 78 FR 59036 - Patient Safety Organizations: Voluntary Relinquishment From Cogent Patient Safety Organization, Inc.

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-25

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Relinquishment From Cogent Patient Safety Organization, Inc. AGENCY: Agency for Healthcare Research and Quality... Patient Safety Organizations (PSOs), which collect, aggregate, and analyze confidential...

  6. Patient safety is not elective: a debate at the NPSF Patient Safety Congress.

    PubMed

    McTiernan, Patricia; Wachter, Robert M; Meyer, Gregg S; Gandhi, Tejal K

    2015-02-01

    The opening keynote session of the 16th Annual National Patient Safety Foundation Patient Safety Congress, held 14-16 May 2014, featured a debate addressing the merits and challenges of accountability with respect to key issues in patient safety. The specific resolution debated was: Certain safety practices should be inviolable, and transgressions should result in penalties, potentially including fines, suspensions, and firing. The themes discussed in the debate are issues that healthcare professionals and leaders commonly struggle with in their day-to-day work. How do we draw a line between systems problems and personal failings? When should clinicians and staff be penalised for failing to follow a known safety protocol? The majority of those who listened to the live debate agreed that it is time to begin holding health professionals accountable when they wilfully or repeatedly violate policies or protocols put in place by their institutions to protect the safety of patients. This article summarises the debate as well as the questions and discussion generated by each side. A video of the original debate can be found at http://bit.ly/Npsf_debate.

  7. Measuring and improving patient safety through health information technology: The Health IT Safety Framework.

    PubMed

    Singh, Hardeep; Sittig, Dean F

    2016-04-01

    Health information technology (health IT) has potential to improve patient safety but its implementation and use has led to unintended consequences and new safety concerns. A key challenge to improving safety in health IT-enabled healthcare systems is to develop valid, feasible strategies to measure safety concerns at the intersection of health IT and patient safety. In response to the fundamental conceptual and methodological gaps related to both defining and measuring health IT-related patient safety, we propose a new framework, the Health IT Safety (HITS) measurement framework, to provide a conceptual foundation for health IT-related patient safety measurement, monitoring, and improvement. The HITS framework follows both Continuous Quality Improvement (CQI) and sociotechnical approaches and calls for new measures and measurement activities to address safety concerns in three related domains: 1) concerns that are unique and specific to technology (e.g., to address unsafe health IT related to unavailable or malfunctioning hardware or software); 2) concerns created by the failure to use health IT appropriately or by misuse of health IT (e.g. to reduce nuisance alerts in the electronic health record (EHR)), and 3) the use of health IT to monitor risks, health care processes and outcomes and identify potential safety concerns before they can harm patients (e.g. use EHR-based algorithms to identify patients at risk for medication errors or care delays). The framework proposes to integrate both retrospective and prospective measurement of HIT safety with an organization's existing clinical risk management and safety programs. It aims to facilitate organizational learning, comprehensive 360 degree assessment of HIT safety that includes vendor involvement, refinement of measurement tools and strategies, and shared responsibility to identify problems and implement solutions. A long term framework goal is to enable rigorous measurement that helps achieve the safety

  8. Addressing Uniqueness and Unison of Reliability and Safety for a Better Integration

    NASA Technical Reports Server (NTRS)

    Huang, Zhaofeng; Safie, Fayssal

    2016-01-01

    Over time, it has been observed that Safety and Reliability have not been clearly differentiated, which leads to confusion, inefficiency, and, sometimes, counter-productive practices in executing each of these two disciplines. It is imperative to address this situation to help Reliability and Safety disciplines improve their effectiveness and efficiency. The paper poses an important question to address, "Safety and Reliability - Are they unique or unisonous?" To answer the question, the paper reviewed several most commonly used analyses from each of the disciplines, namely, FMEA, reliability allocation and prediction, reliability design involvement, system safety hazard analysis, Fault Tree Analysis, and Probabilistic Risk Assessment. The paper pointed out uniqueness and unison of Safety and Reliability in their respective roles, requirements, approaches, and tools, and presented some suggestions for enhancing and improving the individual disciplines, as well as promoting the integration of the two. The paper concludes that Safety and Reliability are unique, but compensating each other in many aspects, and need to be integrated. Particularly, the individual roles of Safety and Reliability need to be differentiated, that is, Safety is to ensure and assure the product meets safety requirements, goals, or desires, and Reliability is to ensure and assure maximum achievability of intended design functions. With the integration of Safety and Reliability, personnel can be shared, tools and analyses have to be integrated, and skill sets can be possessed by the same person with the purpose of providing the best value to a product development.

  9. Patient safety: the what, how, and when.

    PubMed

    Albrecht, Roxie M

    2015-12-01

    Patient safety is a construct that implies behavior intended to minimize the risk of harm to patients through effectiveness and individual performance designed to avoid injuries to patients from the care that is intended to help them. The Accreditation Council for Graduate Medical Education has made patient safety a focused area in the new Clinical Learning Environment Review process. This lecture will focus on definitions of patient safety terminology; describe the culture of patient safety and a just culture; discuss what to report, who to report it too, and methods of conducting patient safety investigations.

  10. 49 CFR 244.15 - Subjects to be addressed in a Safety Integration Plan not involving an amalgamation of operations.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 49 Transportation 4 2010-10-01 2010-10-01 false Subjects to be addressed in a Safety Integration... TRANSPORTATION REGULATIONS ON SAFETY INTEGRATION PLANS GOVERNING RAILROAD CONSOLIDATIONS, MERGERS, AND ACQUISITIONS OF CONTROL Safety Integration Plans § 244.15 Subjects to be addressed in a Safety Integration...

  11. Implementing Patient Safety Initiatives in Rural Hospitals

    ERIC Educational Resources Information Center

    Klingner, Jill; Moscovice, Ira; Tupper, Judith; Coburn, Andrew; Wakefield, Mary

    2009-01-01

    Implementation of patient safety initiatives can be costly in time and energy. Because of small volumes and limited resources, rural hospitals often are not included in nationally driven patient safety initiatives. This article describes the Tennessee Rural Hospital Patient Safety Demonstration project, whose goal was to strengthen capacity for…

  12. Patient blood management equals patient safety.

    PubMed

    Zacharowski, Kai; Spahn, Donat R

    2016-06-01

    Patient blood management (PBM) can be defined in many ways and may consist of hundreds of single measures to improve patient safety. Traditionally, PBM is based on three pillars and defined as (i) optimization of the endogenous red blood cell (RBC) mass through the targeted stimulation of erythropoiesis and the treatment of modifiable underlying disorders; (ii) minimization of diagnostic, interventional, and surgical blood loss to preserve the patient's RBC mass; and (iii) optimization of the patient-specific tolerance to anemia through strict adherence to physiological transfusion thresholds [1-4]. However, for this review, we have chosen the following three peri-interventional parts: (1) diagnosis and therapy of anemia, (2) optimal hemotherapy, and (3) minimization of hospital-acquired anemia. PBM is an evidence-based, multidisciplinary preventive, and therapeutic approach focusing each patient. The PBM concept involves the use of safe and effective medical and surgical methods and techniques designed to prevent peri-interventional anemia, rationalize use of blood products, and set good blood management measures in an effort to improve patient safety and outcome.

  13. 76 FR 60495 - Patient Safety Organizations: Voluntary Relinquishment From the Patient Safety Group

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-29

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Relinquishment From the Patient Safety Group AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS... relinquishment from The Patient Safety Group of its status as a Patient Safety Organization (PSO). The...

  14. 76 FR 71345 - Patient Safety Organizations: Voluntary Relinquishment From Child Health Patient Safety...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-17

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Relinquishment From Child Health Patient Safety Organization, Inc. AGENCY: Agency for Healthcare Research and... relinquishment from Child Health Patient Safety Organization, Inc. of its status as a Patient Safety...

  15. 76 FR 79192 - Patient Safety Organizations: Voluntary Relinquishment From HSMS Patient Safety Organization

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-21

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Relinquishment From HSMS Patient Safety Organization AGENCY: Agency for Healthcare Research and Quality (AHRQ... relinquishment from the HSMS Patient Safety Organization of its status as a Patient Safety Organization...

  16. 76 FR 9351 - Patient Safety Organizations: Voluntary Delisting From West Virginia Center for Patient Safety

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-17

    ... Virginia State Medical. Association (WVSMA), of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109-41, 42 U.S.C. 299b... Patient Safety, a component entity of West Virginia Hospital Association, West Virginia Medical...

  17. Hospital finances and patient safety outcomes.

    PubMed

    Encinosa, William E; Bernard, Didem M

    2005-01-01

    Hospitals recently have experienced greater financial pressures. Whether these financial pressures have led to more patient safety problems is unknown. Using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Data for Florida from 1996 to 2000, this study examines whether financial pressure at hospitals is associated with increases in the rate of patient safety events (e.g., medical errors) for major surgeries. Findings show that patients have significantly higher odds of having adverse patient safety events (nursing-related patient safety events, surgery-related patient safety events, and all likely preventable patient safety events) when hospital profit margins decline over time. The finding that a within-hospital erosion of hospital operating profits increases the rate of adverse patient safety events suggests that any cost-cutting efforts be carefully designed and managed.

  18. Complying with the 2008 National Patient Safety Goals.

    PubMed

    Catalano, Kathleen; Fickenscher, Kevin

    2008-03-01

    In 2003, the joint commission began publishing National Patient Safety Goals (NPSGs) and requiring accredited health care organizations to comply with these goals in an effort to reduce the number of medical errors. THE NPSGS are updated yearly with new requirements to promote specific improvements in patient safety. This article provides a review of the 2008 NPSGs and suggests ways in which information technology systems can address health care organizations' compliance with some of these goals.

  19. Searching for safety: addressing search engine, website, and provider accountability for illicit online drug sales.

    PubMed

    Liang, Bryan A; Mackey, Tim

    2009-01-01

    Online sales of pharmaceuticals are a rapidly growing phenomenon. Yet despite the dangers of purchasing drugs over the Internet, sales continue to escalate. These dangers include patient harm from fake or tainted drugs, lack of clinical oversight, and financial loss. Patients, and in particular vulnerable groups such as seniors and minorities, purchase drugs online either naïvely or because they lack the ability to access medications from other sources due to price considerations. Unfortunately, high risk online drug sources dominate the Internet, and virtually no accountability exists to ensure safety of purchased products. Importantly, search engines such as Google, Yahoo, and MSN, although purportedly requiring "verification" of Internet drug sellers using PharmacyChecker.com requirements, actually allow and profit from illicit drug sales from unverified websites. These search engines are not held accountable for facilitating clearly illegal activities. Both website drug seller anonymity and unethical physicians approving or writing prescriptions without seeing the patient contribute to rampant illegal online drug sales. Efforts in this country and around the world to stem the tide of these sales have had extremely limited effectiveness. Unfortunately, current congressional proposals are fractionated and do not address the key issues of demand by vulnerable patient populations, search engine accountability, and the ease with which financial transactions can be consummated to promote illegal online sales. To deal with the social scourge of illicit online drug sales, this article proposes a comprehensive statutory solution that creates a no-cost/low-cost national Drug Access Program to break the chain of demand from vulnerable patient populations and illicit online sellers, makes all Internet drug sales illegal unless the Internet pharmacy is licensed through a national Internet pharmacy licensing program, prohibits financial transactions for illegal online drug

  20. 75 FR 57477 - Patient Safety Organizations: Voluntary Delisting

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-09-21

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary... Services Research and Patient Safety (CHRP) Patient Safety Organization (PSO). The Patient Safety and... PSOs, which are entities or component organizations whose mission and primary activity is to...

  1. A meta-analysis of personality and workplace safety: addressing unanswered questions.

    PubMed

    Beus, Jeremy M; Dhanani, Lindsay Y; McCord, Mallory A

    2015-03-01

    [Correction Notice: An Erratum for this article was reported in Vol 100(2) of Journal of Applied Psychology (see record 2015-08139-001). Table 3 contained formatting errors. Minus signs used to indicate negative statistical estimates within the table were inadvertently changed to m-dashes. All versions of this article have been corrected.] The purpose of this meta-analysis was to address unanswered questions regarding the associations between personality and workplace safety by (a) clarifying the magnitude and meaning of these associations with both broad and facet-level personality traits, (b) delineating how personality is associated with workplace safety, and (c) testing the relative importance of personality in comparison to perceptions of the social context of safety (i.e., safety climate) in predicting safety-related behavior. Our results revealed that whereas agreeableness and conscientiousness were negatively associated with unsafe behaviors, extraversion and neuroticism were positively associated with them. Of these traits, agreeableness accounted for the largest proportion of explained variance in safety-related behavior and openness to experience was unrelated. At the facet level, sensation seeking, altruism, anger, and impulsiveness were all meaningfully associated with safety-related behavior, though sensation seeking was the only facet that demonstrated a stronger relationship than its parent trait (i.e., extraversion). In addition, meta-analytic path modeling supported the theoretical expectation that personality's associations with accidents are mediated by safety-related behavior. Finally, although safety climate perceptions accounted for the majority of explained variance in safety-related behavior, personality traits (i.e., agreeableness, conscientiousness, neuroticism) still accounted for a unique and substantive proportion of the explained variance. Taken together, these results substantiate the value of considering personality traits as key

  2. Addressing Unison and Uniqueness of Reliability and Safety for Better Integration

    NASA Technical Reports Server (NTRS)

    Huang, Zhaofeng; Safie, Fayssal

    2015-01-01

    For a long time, both in theory and in practice, safety and reliability have not been clearly differentiated, which leads to confusion, inefficiency, and sometime counter-productive practices in executing each of these two disciplines. It is imperative to address the uniqueness and the unison of these two disciplines to help both disciplines become more effective and to promote a better integration of the two for enhancing safety and reliability in our products as an overall objective. There are two purposes of this paper. First, it will investigate the uniqueness and unison of each discipline and discuss the interrelationship between the two for awareness and clarification. Second, after clearly understanding the unique roles and interrelationship between the two in a product design and development life cycle, we offer suggestions to enhance the disciplines with distinguished and focused roles, to better integrate the two, and to improve unique sets of skills and tools of reliability and safety processes. From the uniqueness aspect, the paper identifies and discusses the respective uniqueness of reliability and safety from their roles, accountability, nature of requirements, technical scopes, detailed technical approaches, and analysis boundaries. It is misleading to equate unreliable to unsafe, since a safety hazard may or may not be related to the component, sub-system, or system functions, which are primarily what reliability addresses. Similarly, failing-to-function may or may not lead to hazard events. Examples will be given in the paper from aerospace, defense, and consumer products to illustrate the uniqueness and differences between reliability and safety. From the unison aspect, the paper discusses what the commonalities between reliability and safety are, and how these two disciplines are linked, integrated, and supplemented with each other to accomplish the customer requirements and product goals. In addition to understanding the uniqueness in

  3. 77 FR 11120 - Patient Safety Organizations: Voluntary Relinquishment From UAB Health System Patient Safety...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-02-24

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Relinquishment From UAB Health System Patient Safety Organization AGENCY: Agency for Healthcare Research and... relinquishment from the UAB Health System Patient Safety Organization of its status as a Patient...

  4. Patient Safety Threat - Syringe Reuse

    MedlinePlus

    ... Devices Clinical Reminder: Insulin Pens Publications Infection Control Assessment of Ambulatory Surgical Centers Meetings Insurance Stakeholders Meeting – December 2011 Ambulatory Surgical Centers – October 2010 Safety by Design – May 2010 Sticking with Safety – May 2010 Injection ...

  5. Update on the National Patient Safety Goals--changes for 2005.

    PubMed

    Catalano, Kathleen

    2005-02-01

    Each year sice 2003, the Joint Commission on Accreditation of Healthcare Organizations has established National Patient Safety Goals for accredited health care organizations. The goals are developed to promote improvement in patient safety by helping health care organizations address specific safety concerns. This article discusses the current goals and highlights new information for 2005.

  6. Addressing cardiovascular disease in patients with renal disease.

    PubMed

    Crook, Errol D; Washington, David O

    2002-01-01

    It is well-established that patients with renal disease are at increased risk of cardiovascular disease (CVD) death. Despite better understanding of CVD in endstage renal disease (ESRD) patients and more rigid guidelines addressing the major risk factors for CVD in this population, CVD continues to be the number one cause of death in patients with ESRD. Moreover, higher rates of CVD are seen in patients with moderate, and even mild, renal dysfunction and in patients with albuminuria (micro and macroscopic). Few studies with CVD endpoints have included patients with renal disease. There is sufficient evidence to support appropriate blood pressure reduction as having a beneficial effect on CVD morbidity and mortality in patients with renal disease (especially for patients with diabetes). Data supporting the benefit of modification of other CVD risk factors is not as strong, but current recommendations do stress aggressive control of lipids, smoking cessation, and maintenance of adequate nutritional status. Inclusion of patients with renal disease in studies with CVD endpoints is necessary. Until then, it is generally recommended that CVD risk stratification and modification strategies be applied to this high-risk population.

  7. En route care patient safety: thoughts from the field.

    PubMed

    McNeill, Margaret M; Pierce, Penny; Dukes, Susan; Bridges, Elizabeth J

    2014-08-01

    The purpose of this study was to describe the patient safety culture of en route care in the United States Air Force aeromedical evacuation system. Almost 100,000 patients have been transported since 2001. Safety concerns in this unique environment are complex because of the extraordinary demands of multitasking, time urgency, long duty hours, complex handoffs, and multiple stressors of flight. An internet-based survey explored the perceptions and experiences of safety issues among nursing personnel involved throughout the continuum of aeromedical evacuation care. A convenience sample of 236 nurses and medical technicians from settings representing the continuum was studied. Descriptive and nonparametric statistics were used to analyze the quantitative data, and thematic analysis was applied to the qualitative data. Results indicate that over 90% of respondents agree or strongly agree safety is a priority in their unit and that their unit is responsive to patient safety initiatives. Many respondents described safety incidents or near misses, and these have been categorized as personnel physical capability limitations, environmental threats, medication and equipment issues, and care process problems. Results suggest the care of patients during transport is influenced by the safety culture, human factors, training, experience, and communication. Suggestions to address safety issues emerged from the survey data.

  8. 76 FR 58812 - Patient Safety Organizations: Delisting for Cause of Patient Safety Organization One, Inc.

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-22

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Delisting for Cause of Patient Safety Organization One, Inc. AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice of Delisting. SUMMARY: Patient Safety Organization One, Inc.: AHRQ has...

  9. 76 FR 71345 - Patient Safety Organizations: Voluntary Relinquishment From Emergency Medicine Patient Safety...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-17

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF HEALTH AND... Relinquishment From Emergency Medicine Patient Safety Foundation AGENCY: Agency for Healthcare Research and... relinquishment from Emergency Medicine Patient Safety Foundation of its status as a Patient Safety...

  10. Patient Safety and the Malpractice System.

    PubMed

    Swift, James Q

    2017-02-26

    The cost of health care in the United States and malpractice insurance has escalated greatly over the past 30 years. In an ideal world, the goals of the tort system would be aligned with efforts at improving safety. In fact, there is little evidence that the tort system and the processes of risk management and informed consent have improved patient safety. The article explores the disunion between patient safety and the malpractice system.

  11. JCAHO'S National Patient Safety Goals 2006.

    PubMed

    Catalano, Kathleen

    2006-02-01

    The Joint Commission of Accreditation of Healthcare Organizations released their first set of National Patient Safety Goals in 2002, which became effective in January 2003. This original set of goals is reviewed and a new set published every year. This article provides a review of the 2006 National Patient Safety Goals with an emphasis on perioperative/perianesthesia implications.

  12. Promoting patient safety: implications for pastoral care.

    PubMed

    Berlinger, Nancy

    2004-01-01

    This article provides an overview of current issues in patient safety, the subject of recently-implemented JCAHO standards, with attention to issues of special interest to pastoral care professionals and Clinical Pastoral Education (CPE) students. Case studies of patient safety initiatives in two health care systems are used to illustrate the relationship between institutional core values and the just treatment of injured patients and their families, and to suggest opportunities for chaplains to contribute to patient safety efforts in their institutions. A list of suggested readings and online resources is included.

  13. A first step toward understanding patient safety

    PubMed Central

    2016-01-01

    Patient safety has become an important policy agenda in healthcare systems since publication of the 1999 report entitled "To Err Is Human." The paradigm has changed from blaming the individual for the error to identifying the weakness in the system that led to the adverse events. Anesthesia is one of the first healthcare specialties to adopt techniques and lessons from the aviation industry. The widespread use of simulation programs and the application of human factors engineering to clinical practice are the influences of the aviation industry. Despite holding relatively advanced medical technology and comparable safety records, the Korean health industry has little understanding of the systems approach to patient safety. Because implementation of the existing system and program requires time, dedication, and financial support, the Korean healthcare industry is in urgent need of developing patient safety policies and putting them into practice to improve patient safety before it is too late. PMID:27703622

  14. Patient safety: this is public health.

    PubMed

    Card, Alan J

    2014-01-01

    Avoidable patient harm is a major public health concern, and may already have surpassed heart disease as the leading cause of death in the United States. While the public health community has contributed much to one aspect of patient harm prevention, infection control, the tools and techniques of public health have far more to offer to the emerging field of patient safety science. Patient safety practice has become increasingly professionalized in recent years, but specialist degree programs in the field remain scarce. Healthcare organizations should consider graduate training in public health as an avenue for investing in the professional development of patient safety practitioners, and schools and programs of public health should support further research and teaching to support patient safety improvement.

  15. Improving patient safety to reduce preventable deaths: the case of a California safety net hospital.

    PubMed

    Leach, Linda Searle; Kagawa, Frank; Mayo, Ann; Pugh, Connie

    2012-01-01

    Preventable deaths occur when signs and symptoms of risk and decline are not detected yet are present many hours prior to a deteriorating course. Rapid responses teams (RRTs), also referred to as medical emergency teams (METs) were introduced to improve patient safety by preventing code arrests and death. This research using a case study methodology describes a nurse-led RRT, developed at a large, safety net, teaching hospital in California. Safety-net hospitals are challenged to deliver care and meet the complex needs of vulnerable patient populations. This hospital is a mission driven organization that is focused on the patient and the needs of underserved populations. To respond to the call for reform for patient safety and reduce adverse events, the organization adopted RRTs, early recognition rounds by RRT registered nurses (RNs) and the use of trigger alerts by nursing assistants (NAs) to expand the surveillance and identification of patients most at risk of clinical deterioration. Collaboration with interns and residents (house staff) facilitated their involvement and response to RRT calls. Using quality data from 2005 to 2010, findings from this patient safety innovation address RRT utilization, frequency of non-ICU code arrests, hospital mortality, and post-arrest survival outcomes.

  16. Patient Safety Culture Assessment in Oman

    PubMed Central

    Al-Mandhari, Ahmed; Al-Zakwani, Ibrahim; Al-Kindi, Moosa; Tawilah, Jihane; Dorvlo, Atsu S.S.; Al-Adawi, Samir

    2014-01-01

    Objective To illustrate the patient safety culture in Oman as gleaned via 12 indices of patient safety culture derived from the Hospital Survey on Patient Safety Culture (HSPSC) and to compare the average positive response rates in patient safety culture between Oman and the USA, Taiwan, and Lebanon. Methods This was a cross-sectional research study employed to gauge the performance of HSPSC safety indices among health workers representing five secondary and tertiary care hospitals in the northern region of Oman. The participants (n=398) represented different professional designations of hospital staff. Analyses were performed using univariate statistics. Results The overall average positive response rate for the 12 patient safety culture dimensions of the HSPSC survey in Oman was 58%. The indices from HSPSC that were endorsed the highest included ‘organizational learning and continuous improvement’ while conversely, ‘non-punitive response to errors’ was ranked the least. There were no significant differences in average positive response rates between Oman and the United States (58% vs. 61%; p=0.666), Taiwan (58% vs. 64%; p=0.386), and Lebanon (58% vs. 61%; p=0.666). Conclusion This study provides the first empirical study on patient safety culture in Oman which is similar to those rates reported elsewhere. It highlights the specific strengths and weaknesses which may stem from the specific milieu prevailing in Oman. PMID:25170407

  17. Addressing challenges and needs in patient education targeting hardly reached patients with chronic diseases.

    PubMed

    Varming, Annemarie Reinhardt; Torenholt, Rikke; Møller, Birgitte Lund; Vestergaard, Susanne; Engelund, Gitte

    2015-01-01

    Some patients do not benefit from participation in patient education due to reasons related to disease burden, literacy, and socioeconomic challenges. In this communication, we address more specifically both the challenges that these hardly reached patients face in relation to patient education programs and the challenges educators face when conducting patient education with hardly reached patients. We define principles for the format and content of dialogue tools to better support this patient group within the population of individuals with diabetes.

  18. Addressing challenges and needs in patient education targeting hardly reached patients with chronic diseases

    PubMed Central

    Varming, Annemarie Reinhardt; Torenholt, Rikke; Møller, Birgitte Lund; Vestergaard, Susanne; Engelund, Gitte

    2015-01-01

    Some patients do not benefit from participation in patient education due to reasons related to disease burden, literacy, and socioeconomic challenges. In this communication, we address more specifically both the challenges that these hardly reached patients face in relation to patient education programs and the challenges educators face when conducting patient education with hardly reached patients. We define principles for the format and content of dialogue tools to better support this patient group within the population of individuals with diabetes. PMID:25729695

  19. 75 FR 75471 - Patient Safety Organizations: Voluntary Delisting

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-03

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary... Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act... organizations whose mission and primary activity is to conduct activities to improve patient safety and...

  20. The business case for patient safety.

    PubMed

    Hwang, Raymond W; Herndon, James H

    2007-04-01

    Recent trends have focused attention on improving patient safety in the United States healthcare system. Lapses in patient safety create undue, often preventable, morbidity. These include adverse drug events, adverse surgical events and nosocomial infections. From an organizational perspective, these events are both inefficient and expensive. Many safe practices and quality enhancing improvements, such as computer provider order entry, proper infection surveillance, telemedicine intensive care, and registered nurse staffing are in fact cost-effective. However, in order to fully achieve higher quality, better adverse event reporting and a culture of safety must first be developed. Increased provider recognition, models of success, public awareness and consumer demand are propelling improvements. As we will outline in this review of the current literature, the business case for patient safety is a compelling one, offering substantial economic incentives for achieving the necessary goal of improved patient outcomes.

  1. [Scientific drug safety information for patients' consent].

    PubMed

    Suzuki-Nishimura, Tamiko

    2011-01-01

    One of the important roles of pharmacists is to continue their contributions to new drug discovery and development. However, it seems to be very difficult to obtain patient satisfaction with new drugs. Because new medicines have both benefit and risk, there should be many systems to maximize the safety and efficacy of the drugs. In clinical trials, the rights, safety and welfare of human subjects under the investigator's care must be protected. Good Clinical Practice is a harmonized ICH-guideline, and the safety information of an investigational product is explained to patients who voluntarily enter the clinical trials. Since safety information about investigational products is still limited, subjects are informed about the results of animal experiments and those of finished clinical trials. The sponsor of clinical trials should be responsible for the on-going safety evaluation of the investigational products. When additional safety information is collected in the clinical trials, the written informed consent form should be appropriately revised. During the review process, quality, safety and efficacy of new drugs are evaluated and judged based on the scientific risk-benefit balance. The safety information collected in clinical trials is reflected in the decision-making process written in the review reports. All-case investigation should be also performed until data from a certain number of patients has been accumulated in order to collect early safety and efficacy data. Important messages written in review reports for drug safety and patient consent are explained. Risk communication will improve the application of patients' consent for new drugs.

  2. Addressing conflicts of interest in nanotechnology oversight: lessons learned from drug and pesticide safety testing

    NASA Astrophysics Data System (ADS)

    Elliott, Kevin C.; Volz, David C.

    2012-01-01

    Financial conflicts of interest raise significant challenges for those working to develop an effective, transparent, and trustworthy oversight system for assessing and managing the potential human health and ecological hazards of nanotechnology. A recent paper in this journal by Ramachandran et al., J Nanopart Res, 13:1345-1371 (2011) proposed a two-pronged approach for addressing conflicts of interest: (1) developing standardized protocols and procedures to guide safety testing; and (2) vetting safety data under a coordinating agency. Based on past experiences with standardized test guidelines developed by the international Organization for Economic Cooperation and Development (OECD) and implemented by national regulatory agencies such as the U.S. Environmental Protection Agency (EPA) and Food and Drug Administration (FDA), we argue that this approach still runs the risk of allowing conflicts of interest to influence toxicity tests, and it has the potential to commit regulatory agencies to outdated procedures. We suggest an alternative approach that further distances the design and interpretation of safety studies from those funding the research. In case the two-pronged approach is regarded as a more politically feasible solution, we also suggest three lessons for implementing this strategy in a more dynamic and effective manner.

  3. Iranian Nurses’ Perception of Patient Safety Culture

    PubMed Central

    Bahrami, Mohammad Amin; Chalak, Mahjabin; Montazeralfaraj, Razieh; Dehghani Tafti, Arefeh

    2014-01-01

    Background: In recent decades, patient safety has become a high priority health system issue, due to the high potential of occurring adverse events in health facilities. Objectives: This study was aimed to survey patient safety culture in 2 Iranian educational hospitals. Materials and Methods: In a descriptive, cross-sectional survey, a hospital survey on patient safety culture, was used in two teaching hospitals in Yazd, Iran during 2012. Study population was comprised of the same hospitals' nurses. Stratified-random sampling method was used and distributed among a total of 340 randomly-selected nurses from different units. From all distributed questionnaires, 302 ones were answered completely and afterwards analyzed using SPSS 17. Dimensional- and item-level positive scores were used for results reporting. Additionally descriptive statistics (mean and standard deviation), independent sample t-test and ANOVA were sued for data analyzing. Results: Research findings demonstrated that both hospitals had low to average scores in all dimensions of patient safety culture. Non-punitive response to error, staffing and frequency of events reported had the lowest positive scores of patient safety dimensions with scores 15.26, 19.26, 16.65, 30 and 32.87, 31.10 respectively in Shahid Sadoughi and Shahid Rahnemoon Hospitals. Also only 29.20 and 28.80 percent of nurses in Shahid Sadoughi and Shahid Rahnemoon Hospitals, respectively, evaluated the patient safety grade of their hospital as “excellent” and “very good”. Indeed, the studied hospitals had a statistical difference in 3 dimensions of patient safety culture (frequency of events reported, organizational learning and staffing). (P ≤ 0.05) Conclusions: Our study results were indicating of the challenge of weak patient safety culture, in educational hospitals. Therefore, the issue should be integrated to all policy makers and managerial initiatives in our health system, as a top priority. PMID:24910783

  4. Macroergonomics in Healthcare Quality and Patient Safety

    PubMed Central

    Carayon, Pascale; Karsh, Ben-Tzion; Gurses, Ayse P.; Holden, Richard; Hoonakker, Peter; Hundt, Ann Schoofs; Montague, Enid; Rodriguez, Joy; Wetterneck, Tosha B.

    2014-01-01

    The US Institute of Medicine and healthcare experts have called for new approaches to manage healthcare quality problems. In this chapter, we focus on macroergonomics, a branch of human factors and ergonomics that is based on the systems approach and considers the organizational and sociotechnical context of work activities and processes. Selected macroergonomic approaches to healthcare quality and patient safety are described such as the SEIPS model of work system and patient safety and the model of healthcare professional performance. Focused reviews on job stress and burnout, workload, interruptions, patient-centered care, health IT and medical devices, violations, and care coordination provide examples of macroergonomics contributions to healthcare quality and patient safety. Healthcare systems and processes clearly need to be systematically redesigned; examples of macroergonomic approaches, principles and methods for healthcare system redesign are described. Further research linking macroergonomics and care processes/patient outcomes is needed. Other needs for macroergonomics research are highlighted, including understanding the link between worker outcomes (e.g., safety and well-being) and patient outcomes (e.g., patient safety), and macroergonomics of patient-centered care and care coordination. PMID:24729777

  5. 77 FR 25179 - Patient Safety Organizations: Voluntary Relinquishment From Surgical Safety Institute

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-04-27

    ... the Surgical Safety Institute of its status as a Patient Safety Organization (PSO). The Patient Safety... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Relinquishment From Surgical Safety Institute AGENCY: Agency for Healthcare Research and Quality (AHRQ),...

  6. Structural empowerment, Magnet hospital characteristics, and patient safety culture: making the link.

    PubMed

    Armstrong, Kevin J; Laschinger, Heather

    2006-01-01

    Nurse managers are seeking ways to improve patient safety in their organizations. At the same time, they struggle to address nurse recruitment and retention concerns by focusing on the quality of nurses' work environment. This exploratory study tested a theoretical model, linking the quality of the nursing practice environments to a culture of patient safety. Specific strategies to increase nurses' access to empowerment structures and thereby increase the culture of patient safety are suggested.

  7. 76 FR 58846 - Final Interim Staff Guidance: Review of Evaluation To Address Gas Accumulation Issues in Safety...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-22

    ... From the Federal Register Online via the Government Publishing Office NUCLEAR REGULATORY COMMISSION Final Interim Staff Guidance: Review of Evaluation To Address Gas Accumulation Issues in Safety.... Nuclear Regulatory Commission (NRC) staff is issuing its Final Interim Staff Guidance (ISG)...

  8. Safety and quality in critical patient care.

    PubMed

    González-Méndez, María Isabel; López-Rodríguez, Luís

    The care quality has gradually been placed in the center of the health system, reaching the patient safety a greater role as one of the key dimensions of quality in recent years. The monitoring, measurement and improvement of safety and quality of care in the Intensive Care Unit represent a great challenge for the critical care community. Health interventions carry a risk of adverse events or events that can cause injury, disability and even death in patients. In Intensive Care Unit, the severity of the critical patient, communication barriers, a high number of activities per patient per day, the practice of diagnostic procedures and invasive treatments, and the quantity and complexity of the information received, among others, put at risk these units as areas for the occurrence of adverse events. This article presents some of the strategies and interventions proposed and tested internationally to optimize the care of critical patients and improve the safety culture in the Intensive Care Unit.

  9. Nutrition and patient safety a report from the National Patient Safety Agency (United Kingdom).

    PubMed

    Lecko, Caroline

    2010-01-01

    The National Patient Safety Agency (NPSA), established in 2001 as part of the U.K. National Health Service (NHS), extended it's portfolio of patient safety programmes to include nutrition in 2006. Since 2006 the focus of the NPSA's nutrition programme has been to raise awareness of nutrition as a patient safety issue and to encourage healthcare staff to report nutrition related patient safety incidents to the NPSA's reporting data base, the Reporting and Learning System, to identify key themes and areas for national learning. In the summer of 2009 the NPSA were invited by the International Hospital Federation to join the Improving Infant and Child Food Safety in Health Facilities project as a member of the Advisory Group. This opportunity allowed for the NPSA to share their experience and knowledge of nutrition patient safety themes.

  10. Using social marketing to address barriers and motivators to agricultural safety and health best practices.

    PubMed

    Yoder, Aaron M; Murphy, Dennis J

    2012-01-01

    Social marketing is an intervention development strategy that pays considerable attention to barriers to and motivators for behavioral change or adoption of recommended behaviors. Barriers are obstacles that prevent individuals from changing or adopting behaviors and are often referred to as the "cons" or "costs" of doing something. Motivators, on the other hand, are factors that encourage individuals to change or adopt behaviors and are often referred to as the "pros," "benefits," or "influencing factors" of doing something. Importantly, social marketing does not target education or knowledge change as an end point; rather, it targets behavior change. Studies across several types of desired behaviors (e.g., smoking cessation, weight control, more exercise, sunscreen use, radon testing) using the Stages of Change model have found systematic relationships between stages of change and pros and cons of changing behavior. A review of literature identifies numerous research and intervention studies that directly reference social marketing in agricultural safety and health, studies that identify reasons why parents allow their children to be exposed to hazardous situations on the farm, and reasons why youth engage in risky behaviors, but only two studies were found that show evidence of systematically researching specific behavioral change motivating factors. The authors offer several suggestions to help address issues relating to social marketing and agricultural safety and health.

  11. Postmarket Drug Safety Information for Patients and Providers

    MedlinePlus

    ... Vaccines, Blood & Biologics Animal & Veterinary Cosmetics Tobacco Products Drugs Home Drugs Drug Safety and Availability Postmarket Drug Safety Information for Patients and Providers Postmarket Drug Safety Information for Patients and Providers Share Tweet ...

  12. Patient Safety and Patient Safety Culture in Nephrology Nurse Practice Settings: Issues, Solutions, and Best Practices.

    PubMed

    Kear, Tamara; Ulrich, Beth

    2015-01-01

    In order to assure patient safety, it is necessary to create positive patient safety cultures. This article presents the initial qualitative results from a national study, "Patient Safety Culture in Nephrology Nurse Practice Settings." Based on the responses of participants, themes were identified for both issues and potential solutions and best practices. Issue themes included underreporting of events and near misses, poor staffing ratios, long work hours, communication lapses, and training, infection control, and compliance. Potential solutions and best practice themes included non-punitive and transparent event reporting, fall reduction strategies, improved medication administration practices, and scheduled safety huddles and safety meetings. The results of this landmark study can be used to start conversations and spark education programs to improve patient safety culture in nephrology nurse practice settings.

  13. National Patient Safety Agency: improving patient safety across all critical care areas.

    PubMed

    Keady, Simon; Thacker, Meera

    2008-04-01

    The National Patient Safety Agency (NPSA) reviews patient safety incidents throughout the National Health Service (NHS) in the United Kingdom and aims to initiate preventative measures. Recent alerts include injectable medication, oral syringes for enternal administration, preventing hyponatraemia in children and anticoagulation. This article gives an insight into the rationale and steps currently being undertaken to respond to these recommendations.

  14. How 3 Rural Safety Net Clinics Integrate Care for Patients

    PubMed Central

    Derrett, Sarah; Gunter, Kathryn E.; Nocon, Robert S.; Quinn, Michael T.; Coleman, Katie; Daniel, Donna M.; Wagner, Edward H.; Chin, Marshall H.

    2016-01-01

    Background Integrated care focuses on care coordination and patient centeredness. Integrated care supports continuity of care over time, with care that is coordinated within and between settings and is responsive to patients’ needs. Currently, little is known about care integration for rural patients. Objective To examine challenges to care integration in rural safety net clinics and strategies to address these challenges. Research Design Qualitative case study. Participants Thirty-six providers and staff from 3 rural clinics in the Safety Net Medical Home Initiative. Methods Interviews were analyzed using the framework method with themes organized within 3 constructs: Team Coordination and Empanelment, External Coordination and Partnerships, and Patient-centered and Community-centered Care. Results Participants described challenges common to safety net clinics, including limited access to specialists for Medicaid and uninsured patients, difficulty communicating with external providers, and payment models with limited support for care integration activities. Rurality compounded these challenges. Respondents reported benefits of empanelment and team-based care, and leveraged local resources to support care for patients. Rural clinics diversified roles within teams, shared responsibility for patient care, and colocated providers, as strategies to support care integration. Conclusions Care integration was supported by 2 fundamental changes to organize and deliver care to patients—(1) empanelment with a designated group of patients being cared for by a provider; and (2) a multidisciplinary team able to address rural issues. New funding and organizational initiatives of the Affordable Care Act may help to further improve care integration, although additional solutions may be necessary to address particular needs of rural communities. PMID:25310637

  15. Roundtable on public policy affecting patient safety.

    PubMed

    Crane, Robert M; Raymond, Brian

    2011-03-01

    On April 15, 2010, patient safety experts were assembled to discuss the adequacy of the public policy response to the Institute of Medicine report "To Err is Human" 10 years after its publication. The experts concluded that additional government actions should be considered. Actions that deserve consideration include the development of an educational campaign to improve public and provider understanding of the issue as a means to support change similar to successful public health campaigns, support the evolution of payment reform away from fee for service, create a clearer aim or goal for patient safety activities, support the development and use of better safety measures to judge status and improvement, and support for additional learning of what works particularly on implementation issues. Participants included: Moderator Robert Crane, senior advisor, Kaiser Permanente Participants Doug Bonacum, vice president, Safety Management, Kaiser Permanente Janet Corrigan, PhD, president and CEO, National Quality Forum Helen Darling, MA, president and CEO, National Business Group on Health Susan Edgman-Levitan, PA, executive director, John D. Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital David M. Lawrence, MD, MPH, chairman and CEO (Retired), Kaiser Foundation Health Plan and Hospitals, Inc Lucian Leape, MD, adjunct professor of Health Policy, Harvard School of Public Health Diane C. Pinakiewicz, president, National Patient Safety Foundation Robert M. Wachter, MD, professor and associate chairman, Department of Medicine, University of California, San Francisco.

  16. Patient safety in genomic medicine: an exploratory study

    PubMed Central

    Korngiebel, Diane M.; Fullerton, Stephanie M.; Burke, Wylie

    2016-01-01

    Purpose Concerns about patient safety and the potential for medical error are largely unexplored for genetic testing despite the expansion of test use. In this preliminary qualitative study we sought the views of genetics professionals about error and patient safety concerns in genomic medicine and factors that might mitigate them. Methods Twelve semi-structured interviews with experienced genetics professionals were conducted. Transcripts were analyzed using selective coding for issues related to error definition, mitigation, and communication. Additional thematic analysis captured themes across content categories. Results Key informants suggested that the potential for adverse events exists in all phases of genetic testing, from ordering to analysis, interpretation, and follow-up. A perceived contributor was lack of physician knowledge about genetics, resulting in errors in test ordering and interpretation. The limitations and uncertainty inherent to rapidly evolving technology were also seen as contributing factors. Strategies to prevent errors included physician education, availability of genetic experts for consultation, and enhanced communication such as improved test reports and electronic decision support. Conclusion Genetic testing poses concerns for patient safety, due to errors and the limitations of current tests. As genomic tests are integrated into medical care, anticipating and addressing the patient safety concerns these key informants identified will be crucial. PMID:27011058

  17. An Organizational Learning Framework for Patient Safety.

    PubMed

    Edwards, Marc T

    Despite concerted effort to improve quality and safety, high reliability remains a distant goal. Although this likely reflects the challenge of organizational change, persistent controversy over basic issues suggests that weaknesses in conceptual models may contribute. The essence of operational improvement is organizational learning. This article presents a framework for identifying leverage points for improvement based on organizational learning theory and applies it to an analysis of current practice and controversy. Organizations learn from others, from defects, from measurement, and from mindfulness. These learning modes correspond with contemporary themes of collaboration, no blame for human error, accountability for performance, and managing the unexpected. The collaborative model has dominated improvement efforts. Greater attention to the underdeveloped modes of organizational learning may foster more rapid progress in patient safety by increasing organizational capabilities, strengthening a culture of safety, and fixing more of the process problems that contribute to patient harm.

  18. Improving patient safety by instructional systems design

    PubMed Central

    Battles, J B

    2006-01-01

    Education and training are important elements in patient safety, both as a potential contributing factor to risks and hazards of healthcare associated injury or harm and as an intervention to be used in eliminating or preventing such harm. All too often we have relied on training as the only interventions for patient safety without examining other alternatives or realizing that, in some cases, the training systems themselves are part of the problem. One way to ensure safety by design is to apply established design principles to education and training. Instructional systems design (ISD) is a systematic method of development of education and training programs for improved learner performance. The ISD process involves five integrated steps: analysis, development, design, implementation, and evaluation (ADDIE). The application of ISD using the ADDIE approach can eliminate or prevent education and training from being a contributing factor of health associated injury or harm, and can also be effective in preventing injury or harm. PMID:17142604

  19. Reliability science and patient safety.

    PubMed

    Luria, Joseph W; Muething, Stephen E; Schoettker, Pamela J; Kotagal, Uma R

    2006-12-01

    Reliability is failure-free operation over time--the measurable capability of a process, procedure, or service to perform its intended function. Reliability science has the potential to help health care organizations reduce defects in care, increase the consistency with which care is delivered, and improve patient outcomes. Based on its principles, the Institute for Health care Improvement has developed a three-step model to prevent failures, mitigate the failures that occur, and redesign systems to reduce failures. Lessons may also be learned from complex organizations that have already adopted the principles of reliability science and operate with high rates of reliability. They share a preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and underspecification of structures.

  20. Improving patient safety in haemodialysis

    PubMed Central

    Bray, Benjamin D.; Metcalfe, Wendy

    2015-01-01

    Thomas Inman (1820–76) wrote ‘Practice two things in your dealings with disease: either help or do not harm the patient’, echoing writings from the Hippocratic school. The challenge of practicing safely with the avoidance of complications or harm is perhaps only heightened in the context of modern medical settings such as the haemodialysis unit where complex interventions and treatment are routine. The current issue of CKJ reports two studies aimed at improving the care of haemodialysis patients targeting early use of arteriovenous grafts as access for haemodialysis and the implementation of a dialysis checklist to ensure the prescribed dialysis treatment is delivered. The further challenge of ensuring that such evidence-based tools are used appropriately and consistently falls to all members of the clinical team. PMID:26034585

  1. Collaborative Education To Ensure Patient Safety.

    ERIC Educational Resources Information Center

    National Advisory Council on Nurse Education and Practice, Rockville, MD.

    Results of a joint meeting between national advisory councils in medicine and nursing on physician-nurse collaboration to enhance patient safety are reported. Recommendations on which participants reached consensus are organized by these Institute of Medicine (IOM) themes: establish a national focus to create leadership through research and…

  2. Enhancing Patient Safety through Organizational Learning: Are Patient Safety Indicators a Step in the Right Direction?

    PubMed Central

    Rivard, Peter E; Rosen, Amy K; Carroll, John S

    2006-01-01

    Objective To assess the potential contribution of the Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) to organizational learning for patient safety improvement. Principal Findings Patient safety improvement requires organizational learning at the system level, which entails changes in organizational routines that cut across divisions, professions, and levels of hierarchy. This learning depends on data that are varied along a number of dimensions, including structure-process-outcome and from granular to high-level; and it depends on integration of those varied data. PSIs are inexpensive, easy to use, less subject to bias than some other sources of patient safety data, and they provide reliable estimates of rates of preventable adverse events. Conclusions From an organizational learning perspective, PSIs have both limitations and potential contributions as sources of patient safety data. While they are not detailed or timely enough when used alone, their simplicity and reliability make them valuable as a higher-level safety performance measure. They offer one means for coordination and integration of patient safety data and activity within and across organizations. PMID:16898983

  3. Patient Safety Learning Systems: A Systematic Review and Qualitative Synthesis

    PubMed Central

    Lambrinos, Anna; Holubowich, Corinne

    2017-01-01

    Background A patient safety learning system (sometimes called a critical incident reporting system) refers to structured reporting, collation, and analysis of critical incidents. To inform a provincial working group's recommendations for an Ontario Patient Safety Event Learning System, a systematic review was undertaken to determine design features that would optimize its adoption into the health care system and would inform implementation strategies. Methods The objective of this review was to address two research questions: (a) what are the barriers to and facilitators of successful adoption of a patient safety learning system reported by health professionals and (b) what design components maximize successful adoption and implementation? To answer the first question, we used a published systematic review. To answer the second question, we used scoping study methodology. Results Common barriers reported in the literature by health care professionals included fear of blame, legal penalties, the perception that incident reporting does not improve patient safety, lack of organizational support, inadequate feedback, lack of knowledge about incident reporting systems, and lack of understanding about what constitutes an error. Common facilitators included a non-accusatory environment, the perception that incident reporting improves safety, clarification of the route of reporting and of how the system uses reports, enhanced feedback, role models (such as managers) using and promoting reporting, legislated protection of those who report, ability to report anonymously, education and training opportunities, and clear guidelines on what to report. Components of a patient safety learning system that increased successful adoption and implementation were emphasis on a blame-free culture that encourages reporting and learning, clear guidelines on how and what to report, making sure the system is user-friendly, organizational development support for data analysis to generate

  4. Training and Action for Patient Safety: Embedding Interprofessional Education for Patient Safety within an Improvement Methodology

    ERIC Educational Resources Information Center

    Slater, Beverley L.; Lawton, Rebecca; Armitage, Gerry; Bibby, John; Wright, John

    2012-01-01

    Introduction: Despite an explosion of interest in improving safety and reducing error in health care, one important aspect of patient safety that has received little attention is a systematic approach to education and training for the whole health care workforce. This article describes an evaluation of an innovative multiprofessional, team-based…

  5. Addressing Patient Sexual Orientation in the Undergraduate Medical Education Curriculum

    ERIC Educational Resources Information Center

    Tamas, Rebecca L.; Miller, Karen Hughes; Martin, Leslee J.; Greenberg, Ruth B.

    2010-01-01

    Objective: This study aims to estimate the number of hours dedicated to lesbian, gay, bisexual, and transgender content in one medical school's undergraduate curriculum, compare it to the national average, and identify barriers to addressing this content. Methods: Course and clerkship directors were asked to estimate how many hours they spent on…

  6. 75 FR 57048 - Patient Safety Organizations: Voluntary Delisting

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-09-17

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary... Patient Safety of Chicagoland (CQPS) of its status as a Patient Safety Organization (PSO). The Patient... the listing of PSOs, which are entities or component organizations whose mission and primary...

  7. [Surgical infections as patient safety problems].

    PubMed

    Baranyai, Zsolt; Kulin, László; Jósa, Valéria; Mayer, Akos

    2011-06-01

    Surgical infections are severe complications of surgical interventions and one of the most important patient safety issues. These are associated with increased morbidity, mortality, costs and decreased quality of life. Prevention of infections is essential, while one has to consider pre-, intra- and postoperative factors and procedures in the clinical practice. In this article we summarize the latest recommendations for clinicians based on the relevant published literature.

  8. Impact of a patient safety curriculum for nurse anesthesia students.

    PubMed

    Ardizzone, Laura L; Enlow, William M; Evanina, Eileen Y; Schnall, Rebecca; Currie, Leanne

    2009-12-01

    Patient safety has become an important aspect of national health care initiatives. The purpose of this evaluation was to measure the impact of a patient safety education series for students enrolled in a nurse anesthesia program. Baseline surveys that measured patient safety competencies across three domains, attitudes, skills and knowledge, were administered to the students. A patient safety education series was delivered to the cohort and the survey was then readministered. Mean scores were compared using independent samples t tests. Attitude scores did not change from baseline to posttest. Participants scored higher on posttest means for both the patient safety skills and knowledge domains. Incorporating patient safety content into the nurse anesthesia master's degree curriculum may enhance clinicians' skills and knowledge related to patient safety, and the addition of a patient safety curriculum is important during the formative education process.

  9. Patient safety and the problem of many hands

    PubMed Central

    Dixon-Woods, Mary; Pronovost, Peter

    2016-01-01

    Summary Healthcare worldwide is faced with a crisis of patient safety: every day, everywhere, patients are injured during the course of their care. Notwithstanding occasional successes in relation to specific harms, safety as a system characteristic has remained elusive. We propose that one neglected reason why the safety problem has proved so stubborn is that healthcare suffers from a pathology known in the public administration literature as the problem of many hands. It is a problem that arises in contexts where multiple actors – organizations, individuals, groups – each contribute to effects seen at system level, but it remains difficult to hold any single actor responsible for these effects. Efforts by individual actors, including local quality improvement projects, may have the paradoxical effect of undermining system safety. Many challenges cannot be resolved by individual organisations, since they require whole-sector coordination and action. We call for recognition of the problem of many hands and for attention to be given to how it might most optimally be addressed in a healthcare context. PMID:26912578

  10. Tracking medical devices to ensure patient safety.

    PubMed

    Beyea, Suzanne C

    2003-01-01

    Registered nurses in perioperative settings and managers of perioperative departments must work together to implement policies and procedures to ensure compliance with these very important federal regulations. If the information is not recorded in the proper manner and shared with the manufacturer, patients' safety is at risk. Without the ability to contact physicians and patients, manufacturers cannot alert individuals appropriately if problems arise with a certain device. Tracking devices in the correct manner ensures that patients can be notified expediently. Nurses and managers should examine their current practices to ensure that they are consistent with federal regulations. A regular assessment should be conducted to ensure that tracking forms are completed in an accurate, timely manner, that permission to release a patient's social security number is obtained, and that the hospital is compliant with the FDA's most up-to-date list of devices that must be tracked. All perioperative staff members must receive education about the tracking process in their particular institution and receive updates when the process or FDA regulations change. Maintain patient safety by ensuring that the medical device tracking process is followed accurately and meets federal regulations.

  11. 75 FR 75473 - Patient Safety Organizations: Voluntary Delisting

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-03

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary... Medical, Inc., of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality... or component organizations whose mission and primary activity is to conduct activities to...

  12. 75 FR 57281 - Patient Safety Organizations: Voluntary delisting

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-09-20

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary... Corporation of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement... or component organizations whose mission and primary activity is to conduct activities to...

  13. 75 FR 63498 - Patient Safety Organizations: Voluntary Delisting

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-10-15

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary... Foundation of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement... or component organizations whose mission and primary activity is to conduct activities to...

  14. 75 FR 75472 - Patient Safety Organizations: Voluntary Delisting

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-03

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary... Group, Inc. of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality... or component organizations whose mission and primary activity is to conduct activities to...

  15. Patient safety principles in family medicine residency accreditation standards and curriculum objectives

    PubMed Central

    Kassam, Aliya; Sharma, Nishan; Harvie, Margot; O’Beirne, Maeve; Topps, Maureen

    2016-01-01

    Abstract Objective To conduct a thematic analysis of the College of Family Physicians of Canada’s (CFPC’s) Red Book accreditation standards and the Triple C Competency-based Curriculum objectives with respect to patient safety principles. Design Thematic content analysis of the CFPC’s Red Book accreditation standards and the Triple C curriculum. Setting Canada. Main outcome measures Coding frequency of the patient safety principles (ie, patient engagement; respectful, transparent relationships; complex systems; a just and trusting culture; responsibility and accountability for actions; and continuous learning and improvement) found in the analyzed CFPC documents. Results Within the analyzed CFPC documents, the most commonly found patient safety principle was patient engagement (n = 51 coding references); the least commonly found patient safety principles were a just and trusting culture (n = 5 coding references) and complex systems (n = 5 coding references). Other patient safety principles that were uncommon included responsibility and accountability for actions (n = 7 coding references) and continuous learning and improvement (n = 12 coding references). Conclusion Explicit inclusion of patient safety content such as the use of patient safety principles is needed for residency training programs across Canada to ensure the full spectrum of care is addressed, from community-based care to acute hospital-based care. This will ensure a patient safety culture can be cultivated from residency and sustained into primary care practice. PMID:27965349

  16. Patient safety education among chinese medical undergraduates: An empirical study.

    PubMed

    Li, Gang; Tao, Hong-Bing; Liao, Jia-Zhi; Tang, Jin-Hui; Peng, Fang; Shu, Qin; Li, Wen-Gang; Tu, Shun-Gui; Chen, Zhuo

    2016-10-01

    Patient safety education is conducive to medical students' cognition on patient safety and to improvement of medical quality and safety. Developing patient safety education for medical students is more and more widely recognized by World Health Organization and countries all over the world. However, in China, patient safety courses aiming at medical students are relatively few, and there are few reports about the effect of patient safety courses. This paper explored the influence of patient safety curriculum on medical students' attitude to and knowledge of patient safety. The patient safety curriculum was carried out for 2011-grade undergraduates of Tongji Medical College, Huazhong University of Science and Technology. The students participated in the class according to free choice. After the curriculum, the information of gender, major, attended course, attitude toward patient safety, and knowledge of laws and regulations of the 2011-grade undergraduates were collected. After rejecting invalid questionnaires, the number of undergraduates that participated in the survey was 112 (61 students did not take part in the curriculum; 51 took part in). Chi-square test was applied to analyze patient safety education's influence on medical students' attitude to patient safety and their knowledge mastery situation. The influence of patient safety education on the attitude of medical students to patient safety was not significant, but that on their knowledge of patient safety was remarkable. No matter male or female, as compared with medical students who had not accepted patient safety education, they both had a better acquisition of knowledge after having this education (for male students: 95% CI, 4.556-106.238, P<0.001; for female students: 95% CI, 3.183-33.238, P<0.001). Students majoring in Western Medicine had a relatively better mastery of knowledge of patient safety after receiving patient safety education (95% CI, 6.267-76.271, P<0.001). Short-term patient safety

  17. Fostering innovation, advancing patient safety: the kidney health initiative.

    PubMed

    Archdeacon, Patrick; Shaffer, Rachel N; Winkelmayer, Wolfgang C; Falk, Ronald J; Roy-Chaudhury, Prabir

    2013-09-01

    To respond to the serious and underrecognized epidemic of kidney disease in the United States, the US Food and Drug Administration and the American Society of Nephrology have founded the Kidney Health Initiative-a public-private partnership designed to create a collaborative environment in which the US Food and Drug Administration and the greater kidney community can interact to optimize the evaluation of drugs, devices, biologics, and food products. The Kidney Health Initiative will bring together all the necessary stakeholders, including patients, regulators, industry, health care providers, academics, and other governmental agencies, to improve patient safety and foster innovation. This initiative is intended to enable the kidney community as a whole to provide the right drug, device, or biologic for administration to the right patient at the right time by fostering partnerships that will facilitate development and delivery of those products and addressing challenges that currently impede these goals.

  18. Suicide genes: monitoring cells in patients with a safety switch.

    PubMed

    Eissenberg, Linda G; Rettig, Michael; Dehdashti, Farrokh; Piwnica-Worms, David; DiPersio, John F

    2014-01-01

    Clinical trials increasingly incorporate suicide genes either as direct lytic agents for tumors or as safety switches in therapies based on genetically modified cells. Suicide genes can also be used as non-invasive reporters to monitor the biological consequences of administering genetically modified cells to patients and gather information relevant to patient safety. These genes can monitor therapeutic outcomes addressable by early clinical intervention. As an example, our recent clinical trial used (18)F-9-(4-fluoro-3-hydroxymethylbutyl)guanine ((18)FHBG) and positron emission tomography (PET)/CT scans to follow T cells transduced with herpes simplex virus thymidine kinase after administration to patients. Guided by preclinical data we ultimately hope to discern whether a particular pattern of transduced T cell migration within patients reflects early development of graft vs. host disease. Current difficulties in terms of choice of suicide gene, biodistribution of radiolabeled tracers in humans vs. animal models, and threshold levels of genetically modified cells needed for detection by PET/CT are discussed. As alternative suicide genes are developed, additional radiolabel probes suitable for imaging in patients should be considered.

  19. Promoting patient safety in India: situational analysis and the way forward.

    PubMed

    Madhok, Rajan; Vaid, Sonali; Carson-Stevens, Andrew; Panesar, Sukhmeet; Mathew, Joseph; Roy, Nobhojit; Sangal, Akhil; Datar, Nikhil; Strobl, Judith; Storr, Julie

    2014-01-01

    Unsafe healthcare is a well-recognized issue internationally and is attracting attention in India as well. Drawing upon the various efforts that have been made to address this issue in India and abroad, we explore how we can accelerate developments and build a culture of patient safety in the Indian health sector. Using five international case studies, we describe experiences of promoting patient safety in various ways to inform future developments in India. We offer a roadmap for 2020, which contains suggestions on how India could build a culture of patient safety.

  20. 78 FR 12065 - Patient Safety Organizations: Delisting for Cause for Independent Data Safety Monitoring, Inc.

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-02-21

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Delisting for Cause for Independent Data Safety Monitoring, Inc. AGENCY: Agency for Healthcare Research and Quality..., Inc. due to its failure to correct a deficiency. The Patient Safety and Quality Improvement Act...

  1. Patient Safety in Medical Education: Students’ Perceptions, Knowledge and Attitudes

    PubMed Central

    Nabilou, Bahram; Feizi, Aram; Seyedin, Hesam

    2015-01-01

    Patient safety is a new and challenging discipline in the Iranian health care industry. Among the challenges for patient safety improvement, education of medical and paramedical students is intimidating. The present study was designed to assess students’ perceptions of patient safety, and their knowledge and attitudes to patient safety education. This cross-sectional analytical study was conducted in 2012 at Urmia University of Medical Sciences, West Azerbaijan province, Iran. 134 students studying medicine, nursing, and midwifery were recruited through census for the study. A questionnaire was used for collecting data, which were then analyzed through SPSS statistical software (version 16.0), using Chi-square test, Spearman correlation coefficient, F and LSD tests. A total of 121 questionnaires were completed, and 50% of the students demonstrated good knowledge about patient safety. The relationships between students’ attitudes to patient safety and years of study, sex and course were significant (0.003, 0.001 and 0.017, respectively). F and LSD tests indicated that regarding the difference between the mean scores of perceptions of patient safety and attitudes to patient safety education, there was a significant difference among medical and nursing/midwifery students. Little knowledge of students regarding patient safety indicates the inefficiency of informal education to fill the gap; therefore, it is recommended to consider patient safety in the curriculums of all medical and paramedical sciences and formulate better policies for patient safety. PMID:26322897

  2. Health innovation for patient safety improvement.

    PubMed

    Sellappans, Renukha; Chua, Siew Siang; Tajuddin, Nur Amani Ahmad; Mei Lai, Pauline Siew

    2013-01-01

    Medication error has been identified as a major factor affecting patient safety. Many innovative efforts such as Computerised Physician Order Entry (CPOE), a Pharmacy Information System, automated dispensing machines and Point of Administration Systems have been carried out with the aim of improving medication safety. However, areas remain that require urgent attention. One main area will be the lack of continuity of care due to the breakdown of communication between multiple healthcare providers. Solutions may include consideration of "health smart cards" that carry vital patient medical information in the form of a "credit card" or use of the Malaysian identification card. However, costs and technical aspects associated with the implementation of this health smart card will be a significant barrier. Security and confidentiality, on the other hand, are expected to be of primary concern to patients. Challenges associated with the implementation of a health smart card might include physician buy-in for use in his or her everyday practice. Training and technical support should also be available to ensure the smooth implementation of this system. Despite these challenges, implementation of a health smart card moves us closer to seamless care in our country, thereby increasing the productivity and quality of healthcare.

  3. Addressing Younger Workers’ Needs: The Promoting U through Safety and Health (PUSH) Trial Outcomes

    PubMed Central

    Rohlman, Diane S.; Parish, Megan; Elliot, Diane L.; Hanson, Ginger; Perrin, Nancy

    2016-01-01

    Most younger workers, less than 25 years old, receive no training in worker safety. We report the feasibility and outcomes of a randomized controlled trial of an electronically delivered safety and health curriculum for younger workers entitled, PUSH (Promoting U through Safety and Health). All younger workers (14–24 years old) hired for summer work at a large parks and recreation organization were invited to participate in an evaluation of an online training and randomized into an intervention or control condition. Baseline and end-of-summer online instruments assessed acceptability, knowledge, and self-reported attitudes and behaviors. One-hundred and forty participants (mean age 17.9 years) completed the study. The innovative training was feasible and acceptable to participants and the organization. Durable increases in safety and health knowledge were achieved by intervention workers (p < 0.001, effect size (Cohen’s d) 0.4). However, self-reported safety and health attitudes did not improve with this one-time training. These results indicate the potential utility of online training for younger workers and underscore the limitations of a single training interaction to change behaviors. Interventions may need to be delivered over a longer period of time and/or include environmental components to effectively alter behavior. PMID:27517968

  4. Addressing Younger Workers' Needs: The Promoting U through Safety and Health (PUSH) Trial Outcomes.

    PubMed

    Rohlman, Diane S; Parish, Megan; Elliot, Diane L; Hanson, Ginger; Perrin, Nancy

    2016-08-10

    Most younger workers, less than 25 years old, receive no training in worker safety. We report the feasibility and outcomes of a randomized controlled trial of an electronically delivered safety and health curriculum for younger workers entitled, PUSH (Promoting U through Safety and Health). All younger workers (14-24 years old) hired for summer work at a large parks and recreation organization were invited to participate in an evaluation of an online training and randomized into an intervention or control condition. Baseline and end-of-summer online instruments assessed acceptability, knowledge, and self-reported attitudes and behaviors. One-hundred and forty participants (mean age 17.9 years) completed the study. The innovative training was feasible and acceptable to participants and the organization. Durable increases in safety and health knowledge were achieved by intervention workers (p < 0.001, effect size (Cohen's d) 0.4). However, self-reported safety and health attitudes did not improve with this one-time training. These results indicate the potential utility of online training for younger workers and underscore the limitations of a single training interaction to change behaviors. Interventions may need to be delivered over a longer period of time and/or include environmental components to effectively alter behavior.

  5. A Patient Safety Dilemma: Obesity in the Surgical Patient.

    PubMed

    Goode, Victoria; Phillips, Elayne; DeGuzman, Pamela; Hinton, Ivora; Rovnyak, Virginia; Scully, Kenneth; Merwin, Elizabeth

    2016-12-01

    Patient safety and the delivery of quality care are major concerns for healthcare in the United States. Special populations (eg, obese patients) need study in order to support patient safety, quantify risks, advance education for healthcare-workers, and establish healthcare policy. Obesity is a complex chronic disease and is considered the second leading cause of preventable death in the United States with approximately 300,000 deaths per year. Obesity is recognized by the Agency for Healthcare Research and Quality (AHRQ) as a comorbid condition. These concerns emphasize the need to focus further research on the obese patient. Through the use of clinical and administrative data, this study examines the incidence of adverse outcomes in the obese surgical population through AHRQ Patient Safety Indicators (PSI) and allows for the engagement PSIs as measures to guide and improve performance. In this study, the surgical population was overwhelmingly positive for obesity. Body mass index (BMI) was also a significant positive predictor for 2 of 3 postoperative outcomes. This finding suggests that as BMI reaches the classification of obesity, the risk of these adverse outcomes increases. It further suggests there exists a threshold BMI that requires anticipation of alterations to systems and processes to revise outcomes.

  6. 21 CFR 312.88 - Safeguards for patient safety.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 21 Food and Drugs 5 2010-04-01 2010-04-01 false Safeguards for patient safety. 312.88 Section 312... Severely-debilitating Illnesses § 312.88 Safeguards for patient safety. All of the safeguards incorporated within parts 50, 56, 312, 314, and 600 of this chapter designed to ensure the safety of clinical...

  7. Prioritizing Threats to Patient Safety in Rural Primary Care

    ERIC Educational Resources Information Center

    Singh, Ranjit; Singh, Ashok; Servoss, Timothy J.; Singh, Gurdev

    2007-01-01

    Context: Rural primary care is a complex environment in which multiple patient safety challenges can arise. To make progress in improving safety with limited resources, each practice needs to identify those safety problems that pose the greatest threat to patients and focus efforts on these. Purpose: To describe and field-test a novel approach to…

  8. Cultural factors influencing safety need to be addressed in design and operation of technology.

    PubMed

    Meshkati, N

    1996-10-01

    Cultural factors which influence aviation safety in aircraft design, air traffic control, and human factors training are examined. Analysis of the Avianca Flight 052 crash in New York in January, 1990, demonstrates the catastrosphic effects cultural factors can play. Cultural factors include attitude toward work and technology, organizational hierarchy, religion, and population stereotyping.

  9. Safe at School: Addressing the School Environment and LGBT Safety through Policy and Legislation

    ERIC Educational Resources Information Center

    Biegel, Stuart; Kuehl, Sheila James

    2010-01-01

    Lesbian, gay, bisexual, and transgender (LGBT) students face a unique set of safety concerns each day. Over 85% report being harassed because of their sexual or gender identity, and over 20% report being physically attacked. Far too often teachers and administrators do nothing in response. In part because of this, the suicide rate for LGBT…

  10. Wireless technologies and patient safety in hospitals.

    PubMed

    Boyle, Justin

    2006-06-01

    In the development of policies for wireless technologies, it is important for healthcare organizations to reduce risks to patients from use of wireless devices. Policy should be devised for instructing hospital staff, visitors, and patients, avoiding unwarranted restrictions but not ignoring evidence regarding potential interference problems, and allowing comparison with other clinical facilities of benefits of policy. To inform policy developers and a general audience of hospital personnel, a review was conducted on the safety of wireless devices for communication within hospitals. This review targeted electromagnetic interference effects of devices on medical devices and summarises key recommendations from published reports and international standards. There is consensus that the highest risk of interference occurs with two-way radios used by emergency crews, followed by mobile phones, while radio local area networks produce negligible interference. Wireless technologies are deemed suitable for use throughout hospital areas including intensive care units and operating rooms, given that recommended separation distances from medical equipment are observed.

  11. [Improving patient safety through voluntary peer review].

    PubMed

    Kluge, S; Bause, H

    2015-01-01

    The intensive care unit (ICU) is one area of the hospital in which processes and communication are of primary importance. Errors in intensive care units can lead to serious adverse events with significant consequences for patients. Therefore quality and risk-management are important measures when treating critically ill patients. A pragmatic approach to support quality and safety in intensive care is peer review. This approach has gained significant acceptance over the past years. It consists of mutual visits by colleagues who conduct standardised peer reviews. These reviews focus on the systematic evaluation of the quality of an ICU's structure, its processes and outcome. Together with different associations, the State Chambers of Physicians and the German Medical Association have developed peer review as a standardized tool for quality improvement. The common goal of all stakeholders is the continuous and sustainable improvement in intensive care with peer reviews significantly increasing and improving communication between professions and disciplines. Peer reviews secure the sustainability of planned change processes and consequently lead the way to an improved culture of quality and safety.

  12. [Electronic patient record as the tool for better patient safety].

    PubMed

    Schneider, Henning

    2015-01-01

    Recent studies indicate again that there is a deficit in the use of electronic health records (EHR) in German hospitals. Despite good arguments in favour of their use, such as the rapid availability of data, German hospitals shy away from a wider implementation. The reason is the high cost of installing and maintaining the EHRs, for the benefit is difficult to evaluate in monetary terms for the hospital. Even if a benefit can be shown it is not necessarily evident within the hospital, but manifests itself only in the health system outside. Many hospitals only manage to partly implement EHR resulting in increased documentation requirements which reverse their positive effect.In the United States, electronic medical records are also viewed in light of their positive impact on patient safety. In particular, electronic medication systems prove the benefits they can provide in the context of patient safety. As a result, financing systems have been created to promote the digitalisation of hospitals in the United States. This has led to a large increase in the use of IT systems in the United States in recent years. The Universitätsklinikum Eppendorf (UKE) introduced electronic patient records in 2009. The benefits, in particular as regards patient safety, are numerous and there are many examples to illustrate this position. These positive results are intended to demonstrate the important role EHR play in hospitals. A financing system of the ailing IT landscape based on the American model is urgently needed to benefit-especially in terms of patient safety-from electronic medical records in the hospital.

  13. Applications of Advanced Nondestructive Measurement Techniques to Address Safety of Flight Issues on NASA Spacecraft

    NASA Technical Reports Server (NTRS)

    Prosser, Bill

    2016-01-01

    Advanced nondestructive measurement techniques are critical for ensuring the reliability and safety of NASA spacecraft. Techniques such as infrared thermography, THz imaging, X-ray computed tomography and backscatter X-ray are used to detect indications of damage in spacecraft components and structures. Additionally, sensor and measurement systems are integrated into spacecraft to provide structural health monitoring to detect damaging events that occur during flight such as debris impacts during launch and assent or from micrometeoroid and orbital debris, or excessive loading due to anomalous flight conditions. A number of examples will be provided of how these nondestructive measurement techniques have been applied to resolve safety critical inspection concerns for the Space Shuttle, International Space Station (ISS), and a variety of launch vehicles and unmanned spacecraft.

  14. Bioactive nutrients - Time for tolerable upper intake levels to address safety.

    PubMed

    Yates, Allison A; Erdman, John W; Shao, Andrew; Dolan, Laurie C; Griffiths, James C

    2017-03-01

    There is increasing interest by consumers, researchers, and regulators into the roles that certain bioactive compounds, derived from plants and other natural sources, can play in health maintenance and promotion, and even prolonging a productive quality of life. Research has rapidly emerged suggesting that a wide range of compounds and mixtures in and from plants (such as fruits and vegetables, tea and cocoa) and animals (such as fish and probiotics) may exert substantial health benefits. There is interest in exploring the possibility of establishing recommended intakes or dietary guidance for certain bioactive substances to help educate consumers. A key aspect of establishing dietary guidance is the assessment of safety/toxicity of these substances. Toxicologists need to be involved in both the development of the safety framework and in the evaluation of the science to establish maximum intake/upper limits.

  15. Neuroauditory Toxicity of Artemisinin Combination Therapies—Have Safety Concerns Been Addressed?

    PubMed Central

    Ramos-Martín, Virginia; González-Martínez, Carmen; Mackenzie, Ian; Schmutzhard, Joachim; Pace, Cheryl; Lalloo, David G.; Terlouw, Dianne J.

    2014-01-01

    Although artemisinin-based combination therapies (ACTs) are widely viewed as safe drugs with a wide therapeutic dose range, concerns about neuroauditory safety of artemisinins arose during their development. A decade ago, reviews of human data suggested a potential neuro-ototoxic effect, but the validity of these findings was questioned. With 5–10 years of programmatic use, emerging artemisinin-tolerant falciparum malaria in southeast Asia, and the first calls to consider an increased dose of artemisinins, we review neuroauditory safety data on ACTs to treat uncomplicated falciparum malaria. Fifteen studies reported a neurological or auditory assessment. The large heterogeneity of neuro-ototoxic end points and assessment methodologies and the descriptive nature of assessments hampered a formal meta-analysis and definitive conclusions, but they highlight the persistent lack of data from young children. This subgroup is potentially most vulnerable to any neuroauditory toxicity because of their development stage, increased malaria susceptibility, and repeated ACT exposure in settings lacking robust safety monitoring. PMID:24865683

  16. Assessment of physicians’ addressing sexuality in elderly patients with chronic pain

    PubMed Central

    Cherpak, Guilherme Liausu; dos Santos, Fânia Cristina

    2016-01-01

    ABSTRACT Objective To determine the frequency with which physicians address their older adult patients with chronic pain about the issue of sexuality. Methods It is a cross sectional, descriptive, analytical study in which physicians answered a questionnaire comprising questions related to addressing the issue of sexuality during appointments. Results A sample of 155 physicians was obtained, 63.9% stated they did not address sexuality in medical interviews and 23.2% did it most of the time. The main reasons for not addressing were lack of time, fear of embarrassing the patient and technical inability to address the issue. Conclusion There is a need to develop strategies to increase and improve addressing of sexuality in elderly patients with chronic pain, in order to have better quality of life. PMID:27462890

  17. Patient safety, systems design and ergonomics.

    PubMed

    Buckle, P; Clarkson, P J; Coleman, R; Ward, J; Anderson, J

    2006-07-01

    The complexity of the health care environments necessitates an holistic and systematic ergonomics approach to understand the potential for accidents and errors to occur. The health service is also a socio-technical system, and design needs must be met within this context. This paper aims to present the design challenges and emphasises the specialised needs of the health care sector, when dealing with patient safety. It also provides examples of approaches and methods that ergonomists can bring to help inform our knowledge of these systems and the potential towards improving their safety. Mapping workshops provide an example of such methods. Results from these are used to illustrate how the knowledge base required for better design requirements can be generated. The workshops were developed specifically to help improve the design of medication packaging and thereby reduce the probability of medication error. The issues raised are now the subject of further research, design requirements guidance and new design concepts. The paper illustrates the need to engage with the design community and, through the use of robust scientific methods, to generate appropriate design requirements.

  18. Managing patient safety through NPSGs and employee performance.

    PubMed

    Adair, Liberty

    2010-01-01

    Patient safety can only exist in a culture of patient safety, which implies it is a value perceived by all. Culture predicts safety outcomes and leadership predicts the culture. Leaders are obligated to continually mitigate hazard and take action consciously. Healthcare workers should focus on preventing and reporting mistakes with the National Patient Safety Goals (NPSGs) in mind. These include: accuracy of patient identification, effectiveness of communication among caregivers, improving safety of medications, reducing infections, reducing risk of falls, and encouraging patients to be involved in care. Poor performers and reckless behavior need to be mitigated. If employees recognize their roles in the process, feel empowered,and have appropriate tools, resources,and data to implement solutions, errors can be avoided and patient safety becomes paramount.

  19. 2009 Annual National Patient Safety Foundation Congress: conference proceedings.

    PubMed

    Bonacum, Doug; Corrigan, Janet; Gelinas, Lillee; Pinakiewicz, Diane C; Stepnick, Larry

    2009-09-01

    On May 20 to 22, 2009, the National Patient Safety Foundation (NPSF) held its Annual NPSF Patient Safety Congress in National Harbor, Md. Entitled Patient Safety in Challenging Times: Now More Than Ever, A Critical Need, the meeting focused on the need to strengthen efforts to improve patient safety and quality in the midst of the extraordinary economic challenges facing the nation. The Congress was cochaired by the following distinguished individuals: Janet Corrigan, PhD, MBA, president and chief executive officer, National Quality Forum, Lillee Gelinas, RN, MSN, FAAN, vice president and chief nursing officer, VHA, Inc., Doug Bonacum, MBA, BS, vice president for safety management, Kaiser Permanente, and a member of the Board of Directors of NPSF. The main conference was preceded by 3 concurrent day-long workshops: Leadership Day, Patient Safety 101, and Community Engagement from the Patient and Family Perspective. The Congress featured 4 plenary sessions and 35 breakout sessions. This article provides summaries of the plenary sessions.

  20. Integrated Framework for Patient Safety and Energy Efficiency in Healthcare Facilities Retrofit Projects.

    PubMed

    Mohammadpour, Atefeh; Anumba, Chimay J; Messner, John I

    2016-07-01

    There is a growing focus on enhancing energy efficiency in healthcare facilities, many of which are decades old. Since replacement of all aging healthcare facilities is not economically feasible, the retrofitting of these facilities is an appropriate path, which also provides an opportunity to incorporate energy efficiency measures. In undertaking energy efficiency retrofits, it is vital that the safety of the patients in these facilities is maintained or enhanced. However, the interactions between patient safety and energy efficiency have not been adequately addressed to realize the full benefits of retrofitting healthcare facilities. To address this, an innovative integrated framework, the Patient Safety and Energy Efficiency (PATSiE) framework, was developed to simultaneously enhance patient safety and energy efficiency. The framework includes a step -: by -: step procedure for enhancing both patient safety and energy efficiency. It provides a structured overview of the different stages involved in retrofitting healthcare facilities and improves understanding of the intricacies associated with integrating patient safety improvements with energy efficiency enhancements. Evaluation of the PATSiE framework was conducted through focus groups with the key stakeholders in two case study healthcare facilities. The feedback from these stakeholders was generally positive, as they considered the framework useful and applicable to retrofit projects in the healthcare industry.

  1. Nurse burnout and patient safety outcomes: nurse safety perception versus reporting behavior.

    PubMed

    Halbesleben, Jonathon R B; Wakefield, Bonnie J; Wakefield, Douglas S; Cooper, Lynn B

    2008-08-01

    This article examines the relationship between nurse burnout and patient safety indicators, including both safety perceptions and reporting behavior. Based on the Conservation of Resources model of stress and burnout, it is predicted that burnout will negatively affect both patient safety perceptions and perceived likelihood of reporting events. Nurses from a Veteran's Administration hospital completed the Maslach Burnout Inventory and safety outcomes subset of measures from the Agency for Healthcare Research and Quality Patient Safety Culture measure. After controlling for work-related demographics, multiple regression analysis supported the prediction that burnout was associated with the perception of lower patient safety. Burnout was not associated with event-reporting behavior but was negatively associated with reporting of mistakes that did not lead to adverse events. The findings extend previous research on the relationship between burnout and patient outcomes and offer avenues for future research on how nurse motivation resources are invested in light of their stressful work environment.

  2. Certified Registered Nurse Anesthetist Perceptions of Factors Impacting Patient Safety.

    PubMed

    McMullan, Susan P; Thomas-Hawkins, Charlotte; Shirey, Maria R

    Certified registered nurse anesthetists (CRNAs) provide more than 40 million anesthetics each year in the United States. This article describes a study that investigates relationships among CRNA organizational structures (CRNA practice models, work setting, workload, level of education, work experience), CRNA ratings of patient safety culture, and CRNA adverse anesthesia-related event (ARE) reporting. This is a cross-sectional survey study of 336 CRNAs randomly selected from American Association of Nurse Anesthetists database. Workload was measured using NASA Task-Load Index and the Revised Individual Workload Perception Scale. Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Overall Perceptions of Safety Scale and Hospital Survey on Patient Safety Patient Safety Grade Scale were utilized to measure safety culture. Dependent variables (ARE) included difficult intubation/extubation, inadequate ventilation/oxygenation, and pulmonary aspiration. The Revised Individual Workload Perception Scale workload was significantly associated with ARE. Years' experience and Patient Safety Grade Scale were inversely associated with ARE. Overall Perceptions of Safety Scale was significantly and inversely associated with ARE. Practice model, education, and work setting were not associated with ARE. Based on findings, CRNA workload, years' experience, and patient safety culture may be important markers for ARE. Administrative interventions designed to upgrade patient safety culture and ensure manageable CRNA workload may foster quality patient care.

  3. The Environmental Context of Patient Safety and Medical Errors

    ERIC Educational Resources Information Center

    Wholey, Douglas; Moscovice, Ira; Hietpas, Terry; Holtzman, Jeremy

    2004-01-01

    The environmental context of patient safety and medical errors was explored with specific interest in rural settings. Special attention was paid to unique features of rural health care organizations and their environment that relate to the patient safety issue and medical errors (including the distribution of patients, types of adverse events…

  4. Patient Safety Outcomes in Small Urban and Small Rural Hospitals

    ERIC Educational Resources Information Center

    Vartak, Smruti; Ward, Marcia M.; Vaughn, Thomas E.

    2010-01-01

    Purpose: To assess patient safety outcomes in small urban and small rural hospitals and to examine the relationship of hospital and patient factors to patient safety outcomes. Methods: The Nationwide Inpatient Sample and American Hospital Association annual survey data were used for analyses. To increase comparability, the study sample was…

  5. Health care serial murder: a patient safety orphan.

    PubMed

    Kizer, Kenneth W; Yorker, Beatrice C

    2010-04-01

    Two recent instances of alleged health care serial murder raise questions about the priority of efforts to address this problem and the adequacy of current health care safety systems for preventing such intentionally caused adverse events.

  6. Exploring Operational Safeguards, Safety, and Security by Design to Address Real Time Threats in Nuclear Facilities

    SciTech Connect

    Schanfein, Mark J.; Mladineo, Stephen V.

    2015-07-07

    Over the last few years, significant attention has been paid to both encourage application and provide domestic and international guidance for designing in safeguards and security in new facilities.1,2,3 However, once a facility is operational, safeguards, security, and safety often operate as separate entities that support facility operations. This separation is potentially a serious weakness should insider or outsider threats become a reality.Situations may arise where safeguards detects a possible loss of material in a facility. Will they notify security so they can, for example, check perimeter doors for tampering? Not doing so might give the advantage to an insider who has already, or is about to, move nuclear material outside the facility building. If outsiders break into a facility, the availability of any information to coordinate the facility’s response through segregated alarm stations or a failure to include all available radiation sensors, such as safety’s criticality monitors can give the advantage to the adversary who might know to disable camera systems, but would most likely be unaware of other highly relevant sensors in a nuclear facility.This paper will briefly explore operational safeguards, safety, and security by design (3S) at a high level for domestic and State facilities, identify possible weaknesses, and propose future administrative and technical methods, to strengthen the facility system’s response to threats.

  7. Quality and safety aspects of food products addressing the needs of pregnant women and infants.

    PubMed

    Hoeft, Birgit; Eggersdorfer, Manfred; Heck, Stephan

    2014-01-01

    Food safety is a primary concern for pregnant women and infants as the immune system is weakened during pregnancy and not developed enough in infants, which makes them especially vulnerable to suffering from the negative effects of nonquality food products. However, food contaminations not only affect an individual's health but also a country's economic development, social harmony, food trade and even politics, as seen during the Chinese infant formula crisis in 2008. Thus, quality control is crucial in the production processes in order to have safe food products on the market. But quality control alone is not enough: manufacturers must embrace quality beyond classic in-process parameters and perform a final microbiological analysis at the end of the production process. This requires a clear and trustworthy approach to quality and safety and the involvement of all stakeholders from industry, government and academia over policy makers to consumers. This paper provides an introductory context for current quality management systems and gives real-life examples of challenges that manufacturers face during quality management and control throughout the production process.

  8. Patient safety and quality improvement in rehabilitation medicine.

    PubMed

    Cristian, Adrian; Green, Jonah

    2012-05-01

    Patient safety in medical settings has become a major concern. As more and more individuals seek rehabilitative care for their medical conditions or are referred to rehabilitation specialists with increasingly complex medical conditions, the issue of patient safety in the rehabilitation setting takes on added importance. This article introduces the concepts of patient safety, cognitive biases, systems thinking, and quality improvement as they apply to the rehabilitation medicine.

  9. Assessment of Contributions to Patient Safety Knowledge by the Agency for Healthcare Research and Quality-Funded Patient Safety Projects

    PubMed Central

    Sorbero, Melony E S; Ricci, Karen A; Lovejoy, Susan; Haviland, Amelia M; Smith, Linda; Bradley, Lily A; Hiatt, Liisa; Farley, Donna O

    2009-01-01

    Objective To characterize the activities of projects funded in Agency for Healthcare Research and Quality (AHRQ)' patient safety portfolio and assess their aggregate potential to contribute to knowledge development. Data Sources Information abstracted from proposals for projects funded in AHRQ' patient safety portfolio, information on safety practices from the AHRQ Evidence Report on Patient Safety Practices, and products produced by the projects. Study Design This represented one part of the process evaluation conducted as part of a longitudinal evaluation based on the Context–Input–Process–Product model. Principal Findings The 234 projects funded through AHRQ' patient safety portfolio examined a wide variety of patient safety issues and extended their work beyond the hospital setting to less studied parts of the health care system. Many of the projects implemented and tested practices for which the patient safety evidence report identified a need for additional evidence. The funded projects also generated a substantial body of new patient safety knowledge through a growing number of journal articles and other products. Conclusions The projects funded in AHRQ' patient safety portfolio have the potential to make substantial contributions to the knowledge base on patient safety. The full value of this new knowledge remains to be confirmed through the synthesis of results. PMID:21456108

  10. Human factors systems approach to healthcare quality and patient safety

    PubMed Central

    Carayon, Pascale; Wetterneck, Tosha B.; Rivera-Rodriguez, A. Joy; Hundt, Ann Schoofs; Hoonakker, Peter; Holden, Richard; Gurses, Ayse P.

    2013-01-01

    Human factors systems approaches are critical for improving healthcare quality and patient safety. The SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety is a human factors systems approach that has been successfully applied in healthcare research and practice. Several research and practical applications of the SEIPS model are described. Important implications of the SEIPS model for healthcare system and process redesign are highlighted. Principles for redesigning healthcare systems using the SEIPS model are described. Balancing the work system and encouraging the active and adaptive role of workers are key principles for improving healthcare quality and patient safety. PMID:23845724

  11. Generalized railway tank car safety design optimization for hazardous materials transport: addressing the trade-off between transportation efficiency and safety.

    PubMed

    Saat, Mohd Rapik; Barkan, Christopher P L

    2011-05-15

    North America railways offer safe and generally the most economical means of long distance transport of hazardous materials. Nevertheless, in the event of a train accident releases of these materials can pose substantial risk to human health, property or the environment. The majority of railway shipments of hazardous materials are in tank cars. Improving the safety design of these cars to make them more robust in accidents generally increases their weight thereby reducing their capacity and consequent transportation efficiency. This paper presents a generalized tank car safety design optimization model that addresses this tradeoff. The optimization model enables evaluation of each element of tank car safety design, independently and in combination with one another. We present the optimization model by identifying a set of Pareto-optimal solutions for a baseline tank car design in a bicriteria decision problem. This model provides a quantitative framework for a rational decision-making process involving tank car safety design enhancements to reduce the risk of transporting hazardous materials.

  12. Assessing the relationship between patient safety culture and EHR strategy.

    PubMed

    Ford, Eric W; Silvera, Geoffrey A; Kazley, Abby S; Diana, Mark L; Huerta, Timothy R

    2016-07-11

    Purpose - The purpose of this paper is to explore the relationship between hospitals' electronic health record (EHR) adoption characteristics and their patient safety cultures. The "Meaningful Use" (MU) program is designed to increase hospitals' adoption of EHR, which will lead to better care quality, reduce medical errors, avoid unnecessary cost, and promote a patient safety culture. To reduce medical errors, hospital leaders have been encouraged to promote safety cultures common to high-reliability organizations. Expecting a positive relationship between EHR adoption and improved patient safety cultures appears sound in theory, but it has yet to be empirically demonstrated. Design/methodology/approach - Providers' perceptions of patient safety culture and counts of patient safety incidents are explored in relationship to hospital EHR adoption patterns. Multi-level modeling is employed to data drawn from the Agency for Healthcare Research and Quality's surveys on patient safety culture (level 1) and the American Hospital Association's survey and healthcare information technology supplement (level 2). Findings - The findings suggest that the early adoption of EHR capabilities hold a negative association to the number of patient safety events reported. However, this relationship was not present in providers' perceptions of overall patient safety cultures. These mixed results suggest that the understanding of the EHR-patient safety culture relationship needs further research. Originality/value - Relating EHR MU and providers' care quality attitudes is an important leading indicator for improved patient safety cultures. For healthcare facility managers and providers, the ability to effectively quantify the impact of new technologies on efforts to change organizational cultures is important for pinpointing clinical areas for process improvements.

  13. Safety nets can help address the risks to nutrition from increasing climate variability.

    PubMed

    Alderman, Harold

    2010-01-01

    Models of climate change predict increased variability of weather as well as changes in agro-ecology. The increased variability will pose special challenges for nutrition. This study reviews evidence on climate shocks and nutrition and estimates the economic consequences in terms of reduced schooling and economic productivity stemming from nutritional insults in childhood. Panel data covering up to 20 y indicate that that short-term climate shocks have long-term impacts on children that persist, often into their adult lives. Other studies document the potential for relief programs to offset these shocks providing that the programs can be implemented with flexible financing, rapid identification of those affected by the shock, and timely scale-up. The last of these presumes that programs are already in place with contingency plans drawn up. Arguably, direct food distribution, including that of ready-to-use therapeutic food, may be part of the overall strategy. Even if such programs are too expensive for sustainable widespread use in the prevention of malnutrition, scalable food distribution programs may be cost effective to address the heightened risk of malnutrition following weather-related shocks.

  14. 75 FR 75472 - Patient Safety Organizations: Voluntary Delisting

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-12-03

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary... Group (A Component of Helmet Fire, Inc. of its status as a Patient Safety Organization (PSO). The... the listing of PSOs, which are entities or component organizations whose mission and primary...

  15. Electronic health records and national patient-safety goals.

    PubMed

    Sittig, Dean F; Singh, Hardeep

    2012-11-08

    Hospitals and clinics are adapting to new technologies and implementing electronic health records, but the efforts need to be aligned explicitly with goals for patient safety. EHRs bring the risks of both technical failures and inappropriate use, but they can also help to monitor and improve patient safety.

  16. Using safety crosses for patient self-reflection.

    PubMed

    Silverton, Sarah

    The Productive Mental Health Ward programme has been developed to improve efficiency and safety in the NHS. Patients in a medium-secure mental health unit used patient safety crosses as a tool for self-reflection as part of their recovery journey. This article describes how the project was set up as well as initial findings.

  17. Rural Hospital Patient Safety Systems Implementation in Two States

    ERIC Educational Resources Information Center

    Longo, Daniel R.; Hewett, John E.; Ge, Bin; Schubert, Shari

    2007-01-01

    Context and Purpose: With heightened attention to medical errors and patient safety, we surveyed Utah and Missouri hospitals to assess the "state of the art" in patient safety systems and identify changes over time. This study examines differences between urban and rural hospitals. Methods: Survey of all acute care hospitals in Utah and…

  18. 21 CFR 312.88 - Safeguards for patient safety.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 21 Food and Drugs 5 2011-04-01 2011-04-01 false Safeguards for patient safety. 312.88 Section 312... Severely-debilitating Illnesses § 312.88 Safeguards for patient safety. All of the safeguards incorporated... includes the requirements for informed consent (part 50 of this chapter) and institutional review...

  19. 21 CFR 312.88 - Safeguards for patient safety.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 21 Food and Drugs 5 2012-04-01 2012-04-01 false Safeguards for patient safety. 312.88 Section 312... Severely-debilitating Illnesses § 312.88 Safeguards for patient safety. All of the safeguards incorporated... includes the requirements for informed consent (part 50 of this chapter) and institutional review...

  20. "Is it still safe to eat traditional food?" Addressing traditional food safety concerns in aboriginal communities.

    PubMed

    Bordeleau, Serge; Asselin, Hugo; Mazerolle, Marc J; Imbeau, Louis

    2016-09-15

    Food insecurity is a growing concern for indigenous communities worldwide. While the risk of heavy metal contamination associated to wild food consumption has been extensively studied in the Arctic, data are scarce for the Boreal zone. This study addressed the concerns over possible heavy metal exposure through consumption of traditional food in four Anishnaabeg communities living in the Eastern North American boreal forest. Liver and meat samples were obtained from 196 snowshoe hares (Lepus americanus) trapped during winter 2012 across the traditional lands of the participating communities and within 56-156km of a copper smelter. Interviews were conducted with 78 household heads to assess traditional food habits, focusing on snowshoe hare consumption. Concentrations in most meat and liver samples were below the detection limit for As, Co, Cr, Ni and Pb. Very few meat samples had detectable Cd and Hg concentrations, but liver samples had mean dry weight concentrations of 3.79mg/kg and 0.15mg/kg respectively. Distance and orientation from the smelter did not explain the variability between samples, but percent deciduous and mixed forest cover had a marginal negative effect on liver Cd, Cu and Zn concentrations. The estimated exposition risk from snowshoe hare consumption was low, although heavy consumers could slightly exceed recommended Hg doses. In accordance with the holistic perspective commonly adopted by indigenous people, the nutritional and sociocultural importance of traditional food must be considered in risk assessment. Traditional food plays a significant role in reducing and preventing serious health issues disproportionately affecting First Nations, such as obesity, diabetes, and cardiovascular diseases.

  1. How to monitor patient safety in primary care? Healthcare professionals' views

    PubMed Central

    Samra, R; Car, J; Majeed, A; Vincent, C

    2016-01-01

    Summary Objective To identify patient safety monitoring strategies in primary care. Design Open-ended questionnaire survey. Participants A total of 113 healthcare professionals returned the survey from a group of 500 who were invited to participate achieving a response rate of 22.6%. Setting North-West London, United Kingdom. Method A paper-based and equivalent online survey was developed and subjected to multiple stages of piloting. Respondents were asked to suggest strategies for monitoring patient safety in primary care. These monitoring suggestions were then subjected to a content frequency analysis which was conducted by two researchers. Main Outcome measures Respondent-derived monitoring strategies. Results In total, respondents offered 188 suggestions for monitoring patient safety in primary care. The content analysis revealed that these could be condensed into 24 different future monitoring strategies with varying levels of support. Most commonly, respondents supported the suggestion that patient safety can only be monitored effectively in primary care with greater levels of staffing or with additional resources. Conclusion Approximately one-third of all responses were recommendations for strategies which addressed monitoring of the individual in the clinical practice environment (e.g. GP, practice nurse) to improve safety. There was a clear need for more staff and resource set aside to allow and encourage safety monitoring. Respondents recommended the dissemination of specific information for monitoring patient safety such as distributing the lessons of significant event audits amongst GP practices to enable shared learning. PMID:27540488

  2. Positioning Continuing Education: Boundaries and Intersections between the Domains Continuing Education, Knowledge Translation, Patient Safety and Quality Improvement

    ERIC Educational Resources Information Center

    Kitto, Simon; Bell, Mary; Peller, Jennifer; Sargeant, Joan; Etchells, Edward; Reeves, Scott; Silver, Ivan

    2013-01-01

    Public and professional concern about health care quality, safety and efficiency is growing. Continuing education, knowledge translation, patient safety and quality improvement have made concerted efforts to address these issues. However, a coordinated and integrated effort across these domains is lacking. This article explores and discusses the…

  3. Dimensions of patient safety culture in family practice.

    PubMed

    Palacios-Derflingher, Luz; O'Beirne, Maeve; Sterling, Pam; Zwicker, Karen; Harding, Brianne K; Casebeer, Ann

    2010-01-01

    Safety culture has been shown to affect patient safety in healthcare. While the United States and United Kingdom have studied the dimensions that reflect patient safety culture in family practice settings, to date, this has not been done in Canada. Differences in the healthcare systems between these countries and Canada may affect the dimensions found to be relevant here. Thus, it is important to identify and compare the dimensions from the United States and the United Kingdom in a Canadian context. The objectives of this study were to explore the dimensions of patient safety culture that relate to family practice in Canada and to determine if differences and similarities exist between dimensions found in Canada and those found in previous studies undertaken in the United States and the United Kingdom. A qualitative study was undertaken applying thematic analysis using focus groups with family practice offices and supplementary key stakeholders. Analysis of the data indicated that most of the dimensions from the United States and United Kingdom are appropriate in our Canadian context. Exceptions included owner/managing partner/leadership support for patient safety, job satisfaction and overall perceptions of patient safety and quality. Two unique dimensions were identified in the Canadian context: disclosure and accepting responsibility for errors. Based on this early work, it is important to consider differences in care settings when understanding dimensions of patient safety culture. We suggest that additional research in family practice settings is critical to further understand the influence of context on patient safety culture.

  4. 77 FR 42738 - Patient Safety Organizations: Voluntary Relinquishment From the Coalition for Quality and Patient...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-20

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Relinquishment From the Coalition for Quality and Patient Safety of Chicagoland (CQPS PSO) AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice of Delisting. SUMMARY: The Patient Safety...

  5. 76 FR 7855 - Patient Safety Organizations: Voluntary Delisting From Community Medical Foundation for Patient...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-11

    ... Delisting From Community Medical Foundation for Patient Safety AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice of Delisting. SUMMARY: Community Medical Foundation for Patient Safety... Improvement Act of 2005 (Patient Safety Act), Public Law 109-41,42 U.S.C. 299b-21-- b-26, provides for...

  6. Data protection and the patient's right to safety.

    PubMed

    Herveg, Jean

    2014-06-01

    The article investigates the issue of knowing whether or not the proposal for a general data protection regulation could improve the patient's safety. This has been analyzed through the four main contributions that should be expected at least from data protection to the patient's safety. In our view, data protection should help supporting efficient information systems in healthcare, increasing data quality, strengthening the patient's rights and drawing the legal framework for performing quality control procedures. Compared to the current legal framework, it is not sure that the proposal might improve any of these contributions to the patient's safety.

  7. Measuring Patient Safety in Primary Care: The Development and Validation of the “Patient Reported Experiences and Outcomes of Safety in Primary Care” (PREOS-PC)

    PubMed Central

    Ricci-Cabello, Ignacio; Avery, Anthony J.; Reeves, David; Kadam, Umesh T.; Valderas, Jose M.

    2016-01-01

    PURPOSE We set out to develop and validate a patient-reported instrument for measuring experiences and outcomes related to patient safety in primary care. METHOD The instrument was developed in a multistage process supported by an international expert panel and informed by a systematic review of instruments, a meta-synthesis of qualitative studies, 4 patient focus groups, 18 cognitive interviews, and a pilot study. The trial version of Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) covered 5 domains and 11 scales: practice activation (1 scale); patient activation (1 scale); experiences of patient safety events (1 scale); harm (6 scales); and general perceptions of patient safety (2 scales). The questionnaire was posted to 6,736 patients in 45 practices across England. We used “gold standard” psychometric methods to evaluate its acceptability, reliability, structural and construct validity, and ability to discriminate among practices. RESULTS 1,244 completed questionnaires (18.5%) were returned. Median item-specific response rate was 91.3% (interquartile range 28.0%). No major ceiling or floor effects were observed. All 6 multi-item scales showed high internal consistency (Cronbach’s α 0.75–0.96). Factor analysis, correlation between scales, and known group analyses generally supported structural and construct validity. The scales demonstrated a heterogeneous ability to discriminate between practices. The final version of PREOS-PC consisted of 5 domains, 8 scales, and 58 items. CONCLUSIONS PREOS-PC is a new multi-dimensional patient safety instrument for primary care developed with experts and patients. Initial testing shows its potential for use in primary care, and future developments will further address its use in actual clinical practice. PMID:27184996

  8. Quality and Patient Safety Teams in the Perioperative Setting.

    PubMed

    Serino, Michele Fusco

    2015-12-01

    Quality and patient safety teams in the perioperative setting can provide perioperative personnel with a safety net to prevent avoidable errors, which is a necessity in today's complex surgical world. The primary goal of the quality and patient safety team should be to develop and implement a perioperative quality and patient safety strategic plan. The mission of the plan can be developed by surveying facility employees, choosing a quality methodology, and using an evidence-based approach to develop and implement quality programs and processes. To create and sustain a quality and patient safety team, it is important to select a heterogeneous group; define team roles; identify day-to-day, weekly, and monthly team responsibilities; actively participate in facility committees, meetings, and new employee orientation; conduct audits; and schedule project time.

  9. Patient safety culture: the nursing unit leader's role.

    PubMed

    Sammer, Christine Elizabeth; James, Barbara R

    2011-09-30

    Discussions about a culture of patient safety abound, yet nurse leaders continue to struggle to achieve such a culture in today's complex and fast-paced healthcare environment. In this article the authors discuss the concept of a patient safety culture, present a fictional scenario describing what happened in a hospital that lacked a culture of patient safety, and explain what should have happened in the above scenario. This discussion is offered within a framework consisting of seven driving factors of patient safety. These factors include leadership, evidence-based practice, teamwork, communication, and a learning, just, and patient-centered culture. Throughout, an emphasis is placed on leadership at the unit level. Nurse managers will find practical examples illustrating how leaders can help their teams establish a culture that offers the patient quality care in a safe environment.

  10. Creating a Patient Navigation Model to Address Cervical Cancer Disparities in a Rural Hispanic Farmworker Community

    PubMed Central

    Wells, Kristen J.; Rivera, Maria I.; Proctor, Sara K.; Arroyo, Gloria; Bynum, Shalanda A.; Quinn, Gwendolyn P.; Luque, John S.; Rivera, Marlene; Martinez-Tyson, Dinorah; Meade, Cathy D.

    2013-01-01

    Summary This report describes the implementation of a pilot patient navigation (PN) program created to address cervical cancer disparities in a predominantly Hispanic agricultural community. Since November 2009, a patient navigator has provided services to patients of Catholic Mobile Medical Services (CMMS). The PN program has resulted in the need for additional clinic sessions to accommodate the demand for preventive care at CMMS. PMID:23698685

  11. Addressing the needs of Latinos with type 2 diabetes through online patient education.

    PubMed

    Fitzgerald, Sharon A; Gutierrez Ocampo, Alejandro; Blanco, Kenia Yazmin Reyna; Lewis, Virginia; Cupertino, A Paula; Ellerbeck, Edward F

    2014-09-01

    Patients with Type 2 diabetes are increasingly turning to the Web for information about diabetes and self-management. These sites, however, fail to address the cultural and linguistic needs of the growing community of Latinos with diabetes. The Juntos Controlamos la Diabetes Web site was designed as a low-cost patient education tool to be used by patients, caregivers, and healthcare providers to provide ongoing information about diabetes self-management tailored to the needs of the regional Latino community.

  12. 42 CFR 3.208 - Continued protection of patient safety work product.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 1 2010-10-01 2010-10-01 false Continued protection of patient safety work product... GENERAL PROVISIONS PATIENT SAFETY ORGANIZATIONS AND PATIENT SAFETY WORK PRODUCT Confidentiality and Privilege Protections of Patient Safety Work Product § 3.208 Continued protection of patient safety...

  13. 42 CFR 3.204 - Privilege of patient safety work product.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 1 2010-10-01 2010-10-01 false Privilege of patient safety work product. 3.204... PROVISIONS PATIENT SAFETY ORGANIZATIONS AND PATIENT SAFETY WORK PRODUCT Confidentiality and Privilege Protections of Patient Safety Work Product § 3.204 Privilege of patient safety work product. (a)...

  14. Improving Medication Safety Based on Reports in Computerized Patient Safety Systems.

    PubMed

    Pitkänen, Anneli; Teuho, Susanna; Uusitalo, Marjo; Kaunonen, Marja

    2016-03-01

    In recent years, patient safety has been a serious concern internationally. Medication in particular is a significant area in improving patient safety because medication errors are a crucial clinical problem. This study aimed to explore suggestions to improve medication safety reported via computerized patient safety systems in hospitals. The research data were retrospectively collected from the computerized patient safety incident reporting systems in one university hospital and two regional hospitals in Finland. Open-ended records concerning prescribing medicines (n = 136), dispensing medicines (n = 362), administering medicines to patients (n = 538), and documenting medication (n = 434) were included in the analysis. The data were analyzed by using inductive content analysis. Based on the study findings, there is a need to develop and standardize procedures related to all four parts of medication management process. Moreover, working environment, multiprofessional collaboration, and knowledge and skills of the professionals should be developed. Promoting medication safety in hospitals is an urgent challenge. The study results indicated that computerized patient safety incident reporting systems can provide important qualitative information to improve medication process to be safer.

  15. Association between addressing antiseizure drug side effects and patient-reported medication adherence in epilepsy

    PubMed Central

    Moura, Lidia M V R; Carneiro, Thiago S; Cole, Andrew J; Hsu, John; Vickrey, Barbara G; Hoch, Daniel B

    2016-01-01

    Background and aim Adherence to treatment is a critical component of epilepsy management. This study examines whether addressing antiepileptic drug (AED) side effects at every visit is associated with increased patient-reported medication adherence. Patients and methods This study identified 243 adults with epilepsy who were seen at two academic outpatient neurology settings and had at least two visits over a 3-year period. Demographic and clinical characteristics were abstracted. Evidence that AED side effects were addressed was measured through 1) phone interview (patient-reported) and 2) medical records abstraction (physician-documented). Medication adherence was assessed using the validated Morisky Medication Adherence Scale-4. Complete adherence was determined as answering “no” to all questions. Results Sixty-two (25%) patients completed the interviews. Participants and nonparticipants were comparable with respect to demographic and clinical characteristics; however, a smaller proportion of participants had a history of drug-resistant epilepsy than nonparticipants (17.7% vs 30.9%, P=0.04). Among the participants, evidence that AED side effects were addressed was present in 48 (77%) medical records and reported by 51 (82%) patients. Twenty-eight (45%) patients reported complete medication adherence. The most common reason for incomplete adherence was missed medication due to forgetfulness (n=31, 91%). There was no association between addressing AED side effects (neither physician-documented nor patient-reported) and complete medication adherence (P=0.22 and 0.20). Discussion and conclusion Among patients with epilepsy, addressing medication side effects at every visit does not appear to increase patient-reported medication adherence. PMID:27826186

  16. Addressing intimate partner violence in lesbian, gay, bisexual, and transgender patients.

    PubMed

    Ard, Kevin L; Makadon, Harvey J

    2011-08-01

    The medical community's efforts to address intimate partner violence (IPV) have often neglected members of the lesbian, gay, bisexual, and transgender (LGBT) population. Heterosexual women are primarily targeted for IPV screening and intervention despite the similar prevalence of IPV in LGBT individuals and its detrimental health effects. Here, we highlight the burden of IPV in LGBT relationships, discuss how LGBT and heterosexual IPV differ, and outline steps clinicians can take to address IPV in their LGBT patients.

  17. Making background work visible: opportunities to address patient information needs in the hospital

    PubMed Central

    Kendall, Logan; Mishra, Sonali R.; Pollack, Ari; Aaronson, Barry; Pratt, Wanda

    2015-01-01

    Despite growing use of patient-facing technologies such as patient portals to address information needs for outpatients, we understand little about how patients manage information and use information technologies in an inpatient context. Based on hospital observations and responses to an online questionnaire from previously hospitalized patients and caregivers, we describe information workspace that patients have available to them in the hospital and the information items that patients and caregivers rate as important and difficult to access or manage while hospitalized. We found that patients and caregivers desired information—such as the plan of care and the schedule of activities—that is difficult to access as needed in a hospital setting. Within this study, we describe the various tools and approaches that patients and caregivers use to help monitor their care as well as illuminate gaps in information needs not typically captured by traditional patient portals. PMID:26958295

  18. RFID authentication protocol to enhance patient medication safety.

    PubMed

    Kaul, Sonam Devgan; Awasthi, Amit K

    2013-12-01

    Medication errors can cause substantial harm to patients. Automated patient medication system with RFID technology is purposely used to reduce the medication error, to improve the patient safety, to provide personalized patient medication and identification and also to provide counterfeit protection to the patients. In order to enhance medication safety for patients we propose a new dynamic ID based lightweight RFID authentication protocol. Due to low storage capacity and limited computational and communicational capacity of tags, only pseudo random number generator function, one way hash function and bitwise Xor operation are used in our authentication protocol. The proposed protocol is practical, secure and efficient for health care domain.

  19. Emotional exhaustion and workload predict clinician-rated and objective patient safety

    PubMed Central

    Welp, Annalena; Meier, Laurenz L.; Manser, Tanja

    2015-01-01

    Aims: To investigate the role of clinician burnout, demographic, and organizational characteristics in predicting subjective and objective indicators of patient safety. Background: Maintaining clinician health and ensuring safe patient care are important goals for hospitals. While these goals are not independent from each other, the interplay between clinician psychological health, demographic and organizational variables, and objective patient safety indicators is poorly understood. The present study addresses this gap. Method: Participants were 1425 physicians and nurses working in intensive care. Regression analysis (multilevel) was used to investigate the effect of burnout as an indicator of psychological health, demographic (e.g., professional role and experience) and organizational (e.g., workload, predictability) characteristics on standardized mortality ratios, length of stay and clinician-rated patient safety. Results: Clinician-rated patient safety was associated with burnout, trainee status, and professional role. Mortality was predicted by emotional exhaustion. Length of stay was predicted by workload. Contrary to our expectations, burnout did not predict length of stay, and workload and predictability did not predict standardized mortality ratios. Conclusion: At least in the short-term, clinicians seem to be able to maintain safety despite high workload and low predictability. Nevertheless, burnout poses a safety risk. Subjectively, burnt-out clinicians rated safety lower, and objectively, units with high emotional exhaustion had higher standardized mortality ratios. In summary, our results indicate that clinician psychological health and patient safety could be managed simultaneously. Further research needs to establish causal relationships between these variables and support to the development of managerial guidelines to ensure clinicians’ psychological health and patients’ safety. PMID:25657627

  20. The Informatics Opportunities at the Intersection of Patient Safety and Clinical Informatics

    PubMed Central

    Kilbridge, Peter M.; Classen, David C.

    2008-01-01

    Health care providers have a basic responsibility to protect patients from accidental harm. At the institutional level, creating safe health care organizations necessitates a systematic approach. Effective use of informatics to enhance safety requires the establishment and use of standards for concept definitions and for data exchange, development of acceptable models for knowledge representation, incentives for adoption of electronic health records, support for adverse event detection and reporting, and greater investment in research at the intersection of informatics and patient safety. Leading organizations have demonstrated that health care informatics approaches can improve safety. Nevertheless, significant obstacles today limit optimal application of health informatics to safety within most provider environments. The authors offer a series of recommendations for addressing these challenges. PMID:18436896

  1. Patient safety - the role of human factors and systems engineering.

    PubMed

    Carayon, Pascale; Wood, Kenneth E

    2010-01-01

    Patient safety is a global challenge that requires knowledge and skills in multiple areas, including human factors and systems engineering. In this chapter, numerous conceptual approaches and methods for analyzing, preventing and mitigating medical errors are described. Given the complexity of healthcare work systems and processes, we emphasize the need for increasing partnerships between the health sciences and human factors and systems engineering to improve patient safety. Those partnerships will be able to develop and implement the system redesigns that are necessary to improve healthcare work systems and processes for patient safety.

  2. Work system design for patient safety: the SEIPS model

    PubMed Central

    Carayon, P; Hundt, A Schoofs; Karsh, B‐T; Gurses, A P; Alvarado, C J; Smith, M; Brennan, P Flatley

    2006-01-01

    Models and methods of work system design need to be developed and implemented to advance research in and design for patient safety. In this paper we describe how the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety, which provides a framework for understanding the structures, processes and outcomes in health care and their relationships, can be used toward these ends. An application of the SEIPS model in one particular care setting (outpatient surgery) is presented and other practical and research applications of the model are described. PMID:17142610

  3. Nursing Information Systems Requirements: A Milestone for Patient Outcome and Patient Safety Improvement.

    PubMed

    Farzandipour, Mehrdad; Meidani, Zahra; Riazi, Hossein; Sadeqi Jabali, Monireh

    2016-12-01

    Considering the integral role of understanding users' requirements in information system success, this research aimed to determine functional requirements of nursing information systems through a national survey. Delphi technique method was applied to conduct this study through three phases: focus group method modified Delphi technique and classic Delphi technique. A cross-sectional study was conducted to evaluate the proposed requirements within 15 general hospitals in Iran. Forty-three of 76 approved requirements were clinical, and 33 were administrative ones. Nurses' mean agreements for clinical requirements were higher than those of administrative requirements; minimum and maximum means of clinical requirements were 3.3 and 3.88, respectively. Minimum and maximum means of administrative requirements were 3.1 and 3.47, respectively. Research findings indicated that those information system requirements that support nurses in doing tasks including direct care, medicine prescription, patient treatment management, and patient safety have been the target of special attention. As nurses' requirements deal directly with patient outcome and patient safety, nursing information systems requirements should not only address automation but also nurses' tasks and work processes based on work analysis.

  4. [Patient safety, – a current and ongoing problem].

    PubMed

    Díaz, Carlos Alberto; Braem, Virginia; Giuliani, Amalia; Restelli, Emilio

    2014-04-22

    Patient safety is a current and ongoing problem of increasing importance in healthcare. The implementation of a safety culture leads to behavioral change in all processes and responsibility centers. It means a long, slow, arduous path and requires effort, persistence and commitment, but it is increasingly necessary and indispensable in hospital management.

  5. 78 FR 6819 - Patient Safety Organizations: Voluntary Relinquishment From The Connecticut Hospital Association...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-01-31

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Relinquishment From The Connecticut Hospital Association Federal Patient Safety Organization AGENCY: Agency for... for the formation of Patient Safety Organizations (PSOs), which collect, aggregate, and...

  6. Patient-reported and actionable safety events in CKD.

    PubMed

    Ginsberg, Jennifer S; Zhan, Min; Diamantidis, Clarissa J; Woods, Corinne; Chen, Jingjing; Fink, Jeffrey C

    2014-07-01

    Patients with CKD are at high risk for adverse safety events because of the complexity of their care and impaired renal function. Using data from our observational study of predialysis patients with CKD enrolled in the Safe Kidney Care study, we estimated the baseline frequency of adverse safety events and determined to what extent these events co-occur. We examined patient-reported adverse safety incidents (class I) and actionable safety findings (class II), conditioned on participant use of drugs that might cause such an event, and we used association analysis as a data-mining technique to identify co-occurrences of these events. Of 267 participants, 185 (69.3%) had at least one class I or II event, 102 (38.2%) had more than one event, and 48 (18.0%) had at least one event from both classes. The adjusted conditional rates of class I and class II events ranged from 2.9 to 57.6 per 100 patients and from 2.2 to 8.3 per 100 patients, respectively. The most common conditional class I and II events were patient-reported hypoglycemia and hyperkalemia (serum potassium>5.5 mEq/L), respectively. Reporting of hypoglycemia (in patients with diabetes) and falling or severe dizziness (in patients without diabetes) were most frequently paired with other adverse safety events. We conclude that adverse safety events are common and varied in CKD, with frequent association between disparate events. Further work is needed to define the CKD "safety phenotype" and identify patients at highest risk for adverse safety events.

  7. A Process-Centered Tool for Evaluating Patient Safety Performance and Guiding Strategic Improvement

    DTIC Science & Technology

    2005-01-01

    interdepartmental coordination of patient safety activities, would be crucial for introducing and improving patient safety. Two performance measures received a...seeking feedback and use of the information for improvement and creating a culture of safety. 1.2. Social Responsibility Ethical Behavior: How...all stakeholders, actively seeking feedback on patient safety and using the information for patient safety improvements . • Ensure ethical

  8. Organizing patient safety research to identify risks and hazards

    PubMed Central

    Battles, J; Lilford, R

    2003-01-01

    Patient safety has become an international priority with major research programmes being carried out in the USA, UK, and elsewhere. The challenge is how to organize research efforts that will produce the greatest yield in making health care safer for patients. Patient safety research initiatives can be considered in three different stages: (1) identification of the risks and hazards; (2) design, implementation, and evaluation of patient safety practices; and (3) maintaining vigilance to ensure that a safe environment continues and patient safety cultures remain in place. Clearly, different research methods and approaches are needed at each of the different stages of the continuum. A number of research approaches can be used at stage 1 to identify risks and hazards including the use of medical records and administrative record review, event reporting, direct observation, process mapping, focus groups, probabilistic risk assessment, and safety culture assessment. No single method can be universally applied to identify risks and hazards in patient safety. Rather, multiple approaches using combinations of these methods should be used to increase identification of risks and hazards of health care associated injury or harm to patients. PMID:14645888

  9. Patient safety legislation: a look at health policy development.

    PubMed

    Mattie, Angela S; Ben-Chitrit, Rosalyn

    2007-11-01

    On July 29, 2005, President Bush signed into law the Patient Safety and Quality Improvement Act. This long-awaited bill came after considerable debate in the Senate and the House that focused on patient safety highlighted by the Institute of Medicine's (IOM's) report, To Err Is Human. The IOM report brought the significance of patient safety issues to the national forefront and called for congressional action, but it was 6 years after that report before Congress passed legislation in this area. The article explores the development of patient safety legislation and provides a historical review and analysis of the events leading to the passage of the final bill. It provides background about the major issues requiring resolution and compromise, compares the positions of the competing stakeholders, and describes the importance and degree of influence that can derive from input by stakeholders in the passage of legislation.

  10. Promoting Patient Safety: Results of a TeamSTEPPS® Initiative.

    PubMed

    Gaston, Teresa; Short, Nancy; Ralyea, Christina; Casterline, Gayle

    2016-04-01

    Teamwork is an essential component of communication in a safety-oriented culture. The Joint Commission has identified poor communication as one of the leading causes of patient sentinel events. The aim of this quality improvement project was to design, implement, and evaluate a customized TeamSTEPPS® training program. After implementation, staff perception of teamwork and communication improved. The data support that TeamSTEPPS is a practical, effective, and low-cost patient safety endeavor.

  11. CE: Nursing's Evolving Role in Patient Safety.

    PubMed

    Kowalski, Sonya L; Anthony, Maureen

    2017-02-01

    : Background: In its 1999 report To Err Is Human: Building a Safer Health System, the Institute of Medicine (IOM) suggested that between 44,000 and 98,000 Americans die annually as a result of medical errors. The report urged health care institutions to break the silence surrounding such errors and to implement changes that would promote a culture of safety.

  12. Just Culture: A Foundation for Balanced Accountability and Patient Safety

    PubMed Central

    Boysen, Philip G.

    2013-01-01

    Background The framework of a just culture ensures balanced accountability for both individuals and the organization responsible for designing and improving systems in the workplace. Engineering principles and human factors analysis influence the design of these systems so they are safe and reliable. Methods Approaches for improving patient safety introduced here are (1) analysis of error, (2) specific tools to enhance safety, and (3) outcome engineering. Conclusion The just culture is a learning culture that is constantly improving and oriented toward patient safety. PMID:24052772

  13. Creating a Fellowship Curriculum in Patient Safety and Quality.

    PubMed

    Abookire, Susan A; Gandhi, Tejal K; Kachalia, Allen; Sands, Kenneth; Mort, Elizabeth; Bommarito, Grace; Gagne, Jane; Sato, Luke; Weingart, Saul N

    2016-01-01

    The authors sought to create a curriculum suitable for a newly created clinical fellowship curriculum across Harvard Medical School-affiliated teaching hospitals as part of a newly created 2-year quality and safety fellowship program described in the companion article "Design and Implementation of the Harvard Fellowship in Patient Safety and Quality." The aim of the curriculum development process was to define, coordinate, design, and implement a set of essential skills for future physician-scholars of any specialty to lead operational quality and patient safety efforts. The process of curriculum development and the ultimate content are described in this article.

  14. CKD as an underrecognized threat to patient safety.

    PubMed

    Fink, Jeffrey C; Brown, Jeanine; Hsu, Van Doren; Seliger, Stephen L; Walker, Loreen; Zhan, Min

    2009-04-01

    Chronic kidney disease (CKD) is common, but underrecognized, in patients in the health care system, where improving patient safety is a high priority. Poor disease recognition and several other features of CKD make it a high-risk condition for adverse safety events. In this review, we discuss the unique attributes of CKD that make it a high-risk condition for patient safety mishaps. We point out that adverse safety events in this disease have the potential to contribute to disease progression; namely, accelerated loss of kidney function and increased incidence of end-stage renal disease. We also propose a framework in which to consider patient safety in CKD, highlighting the need for disease-specific safety indicators that reflect unsafe practices in the treatment of this disease. Finally, we discuss the hypothesis that increased recognition of CKD will reduce disease-specific safety events and in this way decrease the likelihood of adverse outcomes, including an accelerated rate of kidney function loss and increased incidence of end-stage renal disease.

  15. Assessing EM Patient Safety and Quality Improvement Milestones Using a Novel Debate Format.

    PubMed

    Mamtani, Mira; Scott, Kevin R; DeRoos, Francis J; Conlon, Lauren W

    2015-11-01

    Graduate medical education is increasingly focused on patient safety and quality improvement; training programs must adapt their curriculum to address these changes. We propose a novel curriculum for emergency medicine (EM) residency training programs specifically addressing patient safety, systems-based management, and practice-based performance improvement, called "EM Debates." Following implementation of this educational curriculum, we performed a cross-sectional study to evaluate the curriculum through resident self-assessment. Additionally, a cross-sectional study to determine the ED clinical competency committee's (CCC) ability to assess residents on specific competencies was performed. Residents were overall very positive towards the implementation of the debates. Of those participating in a debate, 71% felt that it improved their individual performance within a specific topic, and 100% of those that led a debate felt that they could propose an evidence-based approach to a specific topic. The CCC found that it was easier to assess milestones in patient safety, systems-based management, and practice-based performance improvement (sub-competencies 16, 17, and 19) compared to prior to the implementation of the debates. The debates have been a helpful venue to teach EM residents about patient safety concepts, identifying medical errors, and process improvement.

  16. Involving patients in patient safety programmes: A scoping review and consensus procedure by the LINNEAUS collaboration on patient safety in primary care

    PubMed Central

    Trier, Hans; Valderas, Jose M; Wensing, Michel; Martin, Helle Max; Egebart, Jonas

    2015-01-01

    ABSTRACT Background: Patient involvement has only recently received attention as a potentially useful approach to patient safety in primary care. Objective: To summarize work conducted on a scoping review of interventions focussing on patient involvement for patient safety; to develop consensus-based recommendations in this area. Methods: Scoping review of the literature 2006–2011 about methods and effects of involving patients in patient safety in primary care identified evidence for previous experiences of patient involvement in patient safety. This information was fed back to an expert panel for the development of recommendations for healthcare professionals and policy makers. Results: The scoping review identified only weak evidence in support of the effectiveness of patient involvement. Identified barriers included a number of patient factors but also the healthcare workers’ attitudes, abilities and lack of training. The expert panel recommended the integration of patient safety in the educational curricula for healthcare professionals, and expected a commitment from professionals to act as first movers by inviting and encouraging the patients to take an active role. The panel proposed a checklist to be used by primary care clinicians at the point of care for promoting patient involvement. Conclusion: There is only weak evidence on the effectiveness of patient involvement in patient safety. The recommendations of the panel can inform future policy and practice on patient involvement in safety in primary care. PMID:26339838

  17. Suicide Attempts After Emergency Room Visits: The Effect of Patient Safety Goals.

    PubMed

    Robst, John

    2015-12-01

    In 2007 the Joint Commission National Patient Safety Goals included a requirement addressing risks associated with patient suicidality. The rational for this requirement was that suicide has been the most frequently reported sentinel event since the inception of the Sentinel Event Policy in 1996. The Patient Safety Goals on suicide required hospitals implement actions to assess suicide risk, meet client's immediate safety needs and provide information such as a crisis hotline to individuals and family members for crisis situations. This study performed a secondary data analysis to assess the effect of the 2007 Joint Commission Patient Safety Goals on suicide attempts among patients following treatment at hospital emergency rooms among individuals enrolled in the Florida Medicaid program. A difference-in-difference approach compared changes in rates of suicide attempts for individuals with a primary mental health diagnosis and individuals with a physical health diagnosis after emergency room treatment. In the 6 months following treatment, suicide rates declined after implementation of the goals among patients treated for a primary mental health diagnosis, and increased among patients with a poisoning diagnosis, compared to individuals with a physical health diagnosis. The goals were associated with a reduction in suicide attempts after emergency room treatment.

  18. Patient safety in Dutch primary care: a study protocol

    PubMed Central

    2010-01-01

    Background Insight into the frequency and seriousness of potentially unsafe situations may be the first step towards improving patient safety. Most patient safety attention has been paid to patient safety in hospitals. However, in many countries, patients receive most of their healthcare in primary care settings. There is little concrete information about patient safety in primary care in the Netherlands. The overall aim of this study was to provide insight into the current patient safety issues in Dutch general practices, out-of-hours primary care centres, general dental practices, midwifery practices, and allied healthcare practices. The objectives of this study are: to determine the frequency, type, impact, and causes of incidents found in the records of primary care patients; to determine the type, impact, and causes of incidents reported by Dutch healthcare professionals; and to provide insight into patient safety management in primary care practices. Design and methods The study consists of three parts: a retrospective patient record study of 1,000 records per practice type was conducted to determine the frequency, type, impact, and causes of incidents found in the records of primary care patients (objective one); a prospective component concerns an incident-reporting study in each of the participating practices, during two successive weeks, to determine the type, impact, and causes of incidents reported by Dutch healthcare professionals (objective two); to provide insight into patient safety management in Dutch primary care practices (objective three), we surveyed organizational and cultural items relating to patient safety. We analysed the incidents found in the retrospective patient record study and the prospective incident-reporting study by type of incident, causes (Eindhoven Classification Model), actual harm (severity-of-outcome domain of the International Taxonomy of Medical Errors in Primary Care), and probability of severe harm or death. Discussion

  19. Addressing the NASM health and safety standard through curricular changes in a brass methods course: an outcome study.

    PubMed

    Laursen, Amy; Chesky, Kris

    2014-09-01

    The National Association of Schools of Music (NASM) recently ratified a new health and safety standard requiring schools of music to inform students about health concerns related to music. While organizations such as the Performing Arts Medicine Association have developed advisories, the exact implementation is the prerogative of the institution. One possible approach is to embed health education activities into existing methods courses that are routinely offered to music education majors. This may influence student awareness, knowledge, and the perception of competency and responsibility for addressing health risks associated with learning and performing musical instruments. Unfortunately, there are no known lesson plans or curriculum guides for supporting such activities. Therefore, the purpose of this study is to (1) develop course objectives and content that can be applied to a preexisting brass methods course, (2) implement course objectives into a semester-long brass methods course, and (3) test the effectiveness of this intervention on students' awareness, knowledge, perception of competency, and responsibly of health risks that are related to learning and performing brass instruments. Results showcase the potential for modifying methods courses without compromising the other objectives of the course. Additionally, students' awareness, knowledge, perception of competency, and responsibility were positively influenced as measured by changes in pre to post responses to survey group questions.

  20. [Does simulator-based team training improve patient safety?].

    PubMed

    Trentzsch, H; Urban, B; Sandmeyer, B; Hammer, T; Strohm, P C; Lazarovici, M

    2013-10-01

    Patient safety became paramount in medicine as well as in emergency medicine after it was recognized that preventable, adverse events significantly contributed to morbidity and mortality during hospital stay. The underlying errors cannot usually be explained by medical technical inadequacies only but are more due to difficulties in the transition of theoretical knowledge into tasks under the conditions of clinical reality. Crew Resource Management and Human Factors which determine safety and efficiency of humans in complex situations are suitable to control such sources of error. Simulation significantly improved safety in high reliability organizations, such as the aerospace industry.Thus, simulator-based team training has also been proposed for medical areas. As such training is consuming in cost, time and human resources, the question of the cost-benefit ratio obviously arises. This review outlines the effects of simulator-based team training on patient safety. Such course formats are not only capable of creating awareness and improvements in safety culture but also improve technical team performance and emphasize team performance as a clinical competence. A few studies even indicated improvement of patient-centered outcome, such as a reduced rate of adverse events but further studies are required in this respect. In summary, simulator-based team training should be accepted as a suitable strategy to improve patient safety.

  1. Patient safety goals for the proposed Federal Health Information Technology Safety Center.

    PubMed

    Sittig, Dean F; Classen, David C; Singh, Hardeep

    2015-03-01

    The Office of the National Coordinator for Health Information Technology is expected to oversee creation of a Health Information Technology (HIT) Safety Center. While its functions are still being defined, the center is envisioned as a public-private entity focusing on promotion of HIT related patient safety. We propose that the HIT Safety Center leverages its unique position to work with key administrative and policy stakeholders, healthcare organizations (HCOs), and HIT vendors to achieve four goals: (1) facilitate creation of a nationwide 'post-marketing' surveillance system to monitor HIT related safety events; (2) develop methods and governance structures to support investigation of major HIT related safety events; (3) create the infrastructure and methods needed to carry out random assessments of HIT related safety in complex HCOs; and (4) advocate for HIT safety with government and private entities. The convening ability of a federally supported HIT Safety Center could be critically important to our transformation to a safe and effective HIT enabled healthcare system.

  2. Gun Safety Management with Patients at Risk for Suicide

    ERIC Educational Resources Information Center

    Simon, Robert I.

    2007-01-01

    Guns in the home are associated with a five-fold increase in suicide. All patients at risk for suicide must be asked if guns are available at home or easily accessible elsewhere, or if they have intent to buy or purchase a gun. Gun safety management requires a collaborative team approach including the clinician, patient, and designated person…

  3. The Helsinki Declaration on Patient Safety in Anaesthesiology.

    PubMed

    Mellin-Olsen, Jannicke; Staender, Sven; Whitaker, David K; Smith, Andrew F

    2010-07-01

    Anaesthesiology, which includes anaesthesia, perioperative care, intensive care medicine, pain therapy and emergency medicine, has always participated in systematic attempts to improve patient safety. Anaesthesiologists have a unique, cross-specialty opportunity to influence the safety and quality of patient care. Past achievements have allowed our specialty a perception that it has become safe, but there should be no room for complacency when there is more to be done. Increasingly older and sicker patients, more complex surgical interventions, more pressure on throughput, new drugs and devices and simple chance all pose hazards in the work of anaesthesiologists. In response to this increasingly difficult and complex working environment, the European Board of Anaesthesiology (EBA), in cooperation with the European Society of Anaesthesiology (ESA), has produced a blueprint for patient safety in anaesthesiology. This document, to be known as the Helsinki Declaration on Patient Safety in Anaesthesiology, was endorsed by these two bodies together with the World Health Organization (WHO), the World Federation of Societies of Anaesthesiologists (WFSA), and the European Patients' Federation (EPF) at the Euroanaesthesia meeting in Helsinki in June 2010. The Declaration represents a shared European view of that which is worthy, achievable, and needed to improve patient safety in anaesthesiology in 2010. The Declaration recommends practical steps that all anaesthesiologists who are not already using them can successfully include in their own clinical practice. In parallel, EBA and ESA have launched a joint patient safety task-force in order to put these recommendations into practice. It is planned to review this Declaration document regularly.

  4. Spirituality. 2: Exploring how to address patients' spiritual needs in practice.

    PubMed

    Sartori, Penny

    Although meeting patients' spiritual needs is important, many nurses are uncertain about what spiritual care involves and lack confidence in this area. This second article in a two part series on spirituality considers ways of addressing spiritual needs and provides an overview of the principles of assessment and implementation. Part 1 explored definitions of spirituality, the difference between religion and spirituality, and finding meaning in illness.

  5. Promoting safety of postoperative orthopaedic patients with obstructive sleep apnea.

    PubMed

    Veney, Amy J

    2013-01-01

    Orthopaedic patients with obstructive sleep apnea are at risk for postoperative complications related to administration of pain medications, anxiolytics, and antiemetics. They are more likely to experience respiratory and cardiac complications, be transferred to an intensive care unit, or have an increased length of stay in the hospital. This informational article is for nurses who care for postoperative orthopaedic patients with obstructive sleep apnea. The focus is on promoting patient safety through communication, vigilant postoperative sedation assessment, and nursing interventions that include appropriate patient positioning, patient education, and involving patients and their families in care.

  6. Regulation of Health Policy: Patient Safety and the States

    DTIC Science & Technology

    2005-05-01

    report on patient safety, the Institute of Medicine recommended a nationwide mandatory reporting system to collect standardized information about...adverse events. Efforts at instituting a national system have stalled, and both State legislatures and private or quasi-regulatory organizations have...boundaries that discourage adverse event reporting, replacing them with a “safety culture.” This research examines the role of State legislatures in

  7. 42 CFR 3.210 - Required disclosure of patient safety work product to the Secretary.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 1 2010-10-01 2010-10-01 false Required disclosure of patient safety work product... HUMAN SERVICES GENERAL PROVISIONS PATIENT SAFETY ORGANIZATIONS AND PATIENT SAFETY WORK PRODUCT Confidentiality and Privilege Protections of Patient Safety Work Product § 3.210 Required disclosure of...

  8. 76 FR 60495 - Patient Safety Organizations: Voluntary Relinquishment From Illinois PSO

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-29

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary... from the Illinois PSO of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109-41, 42 U.S.C. 299b-21--b-26,...

  9. 76 FR 60494 - Patient Safety Organizations: Voluntary Relinquishment From HPI-PSO

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-29

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary..., a component entity of Healthcare Performance Improvement, LLC, of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law...

  10. 78 FR 17212 - Patient Safety Organizations: Voluntary Relinquishment From QAISys, Inc.

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-20

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary... of delisting. SUMMARY: The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109-41, 42 U.S.C. 299b-21-- b-26, provides for the formation of Patient Safety...

  11. 76 FR 7854 - Patient Safety Organizations: Voluntary Delisting From Lumetra PSO

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-11

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary... PSO, a component entity of Lumetra Healthcare Solutions, of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law...

  12. 78 FR 70560 - Patient Safety Organizations: Voluntary Relinquishment From Morgridge Institute for Research PSO

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-11-26

    ... Research and Quality Patient Safety Organizations: Voluntary Relinquishment From Morgridge Institute for.... SUMMARY: The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109-41, 42 U.S.C. 299b-21-b-26, provides for the formation of Patient Safety Organizations (PSOs),...

  13. 77 FR 25179 - Patient Safety Organizations: Expired Listing for Medkinetics, LLC

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-04-27

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Expired Listing... as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorizes the listing of PSOs, which are entities or component organizations...

  14. 76 FR 74788 - Patient Safety Organizations: Voluntary Relinquishment From HealthWatch, Inc.

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-01

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary...Watch, Inc. of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109-41, 42 U.S.C. 299b-21--b-26, provides for...

  15. 76 FR 7854 - Patient Safety Organizations: Voluntary Delisting From Quality Excellence, Inc./PSO

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-11

    ... Medical Care, of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109-41, 42 U.S.C. 299b-21--b-26, provides for the... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations:...

  16. Analysis of the attitudes and needs/demands of dental practitioners in the field of patient safety and risk management.

    PubMed

    Yamalik, Nermin; Van Dijk, Ward

    2013-12-01

    Patient safety is a relatively new discipline aimed at improving the quality of care, minimising treatment errors and improving the safety of patients. Although health professions always have a specific concern for patient safety, few practitioners have a clear understanding of the broad context and not all health-care providers practice it. This might well be because of limited availability of information and materials as well as a lack of national or international laws and regulations. Thus, through member National Dental Associations (NDAs) of FDI (World Dental Federation), the present study aimed at analysing the attitudes of dental practitioners to the issues of patient safety and risk management, and the availability of materials and laws and regulations. Determination of their specific needs and demands in these fields was also attempted. For this purpose, an online questionnaire was developed for the member NDAs to respond. Questions mainly focused on the awareness regarding patient safety, availability of materials and regulations and the particular topics for which dentists needed further knowledge and information. A total of 40 responses were received. While some countries lack any documents, patient safety documents and materials were available in some countries but they were mostly limited to infection control and radiation protection and did not address other important aspects of patient safety. The NDAs clearly demanded more information. A significant number of countries also lacked national laws and/or regulations regarding patient safety. Although dentistry always has a genuine concern for patient safety, the findings of the survey suggest that yet more efforts are needed to improve the knowledge, understanding and awareness of dental practitioners regarding its broad context and the relatively 'new' patient safety culture. NDAs, dental educators, national, regional and international dental organisations and health authorities all can play

  17. [Patient safety: the need for a national strategy].

    PubMed

    Sousa, Paulo

    2006-01-01

    Patient safety has become a core issue for many modern healthcare systems. All healthcare systems around the world occasionally and unintentionally harm patients whom they are seeking to help. In recognition of this, patient safety has become a fundamental part of the drive to improve quality in many countries. The effects of harming a patient are widespread. There can be devastating emotional and physical consequence for patients and their families. For the staff involved too, incidents can be distressing, while members of their clinical teams can become demoralised and disaffected. Safety incidents also incur costs through litigation and extra treatment. Patient safety is nowadays a serious problem of public health, with several implications in different clinical areas and level of care. It is crucial to establish priorities, hierarchy's interventions and engaged all stakeholders who are involved around this big issue. In other word, it is important to define a strategy that could reflect a global framework, which allow us to integrate, articulate and be actors action-oriented, with the final aim of reducing the possibilities to harm patients. Consequently, these could contribute for a health care delivery of excellence and based on the best evidence. In the last few years, several studies have estimated that around 4% to 17% of patients have experienced an adverse event, and that up to half of these incidents could have been prevented. Many of them have also showed that, the best way of reducing error rates, is to target the underlying systems failures, rather than take actions against individual members of staff. We should recognise that healthcare will always involve risk, but that these risks can be reduced by analysing and tackling the root causes of patient safety incidents. It is important to promote an open and fair culture, and to encourage staff to report when things have gone wrong.

  18. Experience of providing cultural safety in mental health to Aboriginal patients: A grounded theory study.

    PubMed

    McGough, Shirley; Wynaden, Dianne; Wright, Michael

    2017-02-06

    The need for mental health clinicians to practice cultural safety is vital in ensuring meaningful care and in moving towards improving the mental health outcomes for Aboriginal people. The concept of cultural safety is particularly relevant to mental health professionals as it seeks to promote cultural integrity and the promotion of social justice, equity and respect. A substantive theory that explained the experience of providing cultural safety in mental health care to Aboriginal patients was developed using grounded theory methodology. Mental health professionals engaged in a social psychological process, called seeking solutions by navigating the labyrinth to overcome the experience of being unprepared. During this process participants moved from a state of being unprepared to one where they began to navigate the pathway of cultural safety. The findings of this research suggest health professionals have a limited understanding of the concept of cultural safety. The experience of providing cultural safety has not been adequately addressed by organizations, health services, governments, educational providers and policy makers. Health services, organizations and government agencies must work with Aboriginal people to progress strategies that inform and empower staff to practice cultural safety.

  19. [Demonstrating patient safety requires acceptance of a broader scientific palette].

    PubMed

    Leistikow, I

    2017-01-01

    It is high time the medical community recognised that patient-safety research can be assessed using other scientific methods than the traditional medical ones. There is often a fundamental mismatch between the methodology of patient-safety research and the methodology used to assess the quality of this research. One example is research into the reliability and validity of record review as a method for detecting adverse events. This type of research is based on logical positivism, while record review itself is based on social constructivism. Record review does not lead to "one truth": adverse events are not measured on the basis of the records themselves, but by weighing the probability of certain situations being classifiable as adverse events. Healthcare should welcome behavioural and social sciences to its scientific palette. Restricting ourselves to the randomised control trial paradigm is short-sighted and dangerous; it deprives patients of much-needed improvements in safety.

  20. Patient safety education for undergraduate medical students: a systematic review

    PubMed Central

    2011-01-01

    Background To reduce harm caused by health care is a global priority. Medical students should be able to recognize unsafe conditions, systematically report errors and near misses, investigate and improve such systems with a thorough understanding of human fallibility, and disclose errors to patients. Incorporating the knowledge of how to do this into the medical student curriculum is an urgent necessity. This paper aims to systematically review the literature about patient safety education for undergraduate medical students in terms of its content, teaching strategies, faculty availability and resources provided so as to identify evidence on how to promote patient safety in the curriculum for medical schools. This paper includes a perspective from the faculty of a medical school, a major hospital and an Evidence Based Medicine Centre in Sichuan Province, China. Methods We searched MEDLINE, ERIC, Academic Source Premier(ASP), EMBASE and three Chinese Databases (Chinese Biomedical Literature Database, CBM; China National Knowledge Infrastructure, CNKI; Wangfang Data) from 1980 to Dec. 2009. The pre-specified form of inclusion and exclusion criteria were developed for literature screening. The quality of included studies was assessed using Darcy Reed and Gemma Flores-Mateo criteria. Two reviewers selected the studies, undertook quality assessment, and data extraction independently. Differing opinions were resolved by consensus or with help from the third person. Results This was a descriptive study of a total of seven studies that met the selection criteria. There were no relevant Chinese studies to be included. Only one study included patient safety education in the medical curriculum and the remaining studies integrated patient safety into clinical rotations or medical clerkships. Seven studies were of a pre and post study design, of which there was only one controlled study. There was considerable variation in relation to contents, teaching strategies, faculty

  1. Modeling Safety Outcomes on Patient Care Units

    NASA Astrophysics Data System (ADS)

    Patil, Anita; Effken, Judith; Carley, Kathleen; Lee, Ju-Sung

    In its groundbreaking report, "To Err is Human," the Institute of Medicine reported that as many as 98,000 hospitalized patients die each year due to medical errors (IOM, 2001). Although not all errors are attributable to nurses, nursing staff (registered nurses, licensed practical nurses, and technicians) comprise 54% of the caregivers. Therefore, it is not surprising, that AHRQ commissioned the Institute of Medicine to do a follow-up study on nursing, particularly focusing on the context in which care is provided. The intent was to identify characteristics of the workplace, such as staff per patient ratios, hours on duty, education, and other environmental characteristics. That report, "Keeping Patients Safe: Transforming the Work Environment of Nurses" was published this spring (IOM, 2004).

  2. The patient's role in patient safety and the importance of a dedicated vascular access team.

    PubMed

    Shemesh, David; Olsha, Oded; Goldin, Ilya; Danin, Sigalit

    2015-01-01

    The role of dialysis patients in ensuring their own safety throughout the process of vascular access construction should be far from negligible. Patients can make important contributions to their safety starting in the predialysis stage, via vascular access construction and through the experience of chronic hemodialysis. Currently, patients assume a passive role and their empowerment requires both patients and caregivers to overcome many personal and cultural barriers, thus encouraging safety-related behavior. There are many opportunities for end-stage renal failure patients to be involved in every stage of their disease. In this chapter, we discuss how hemodialysis patients can participate in patient safety, including some of the main opportunities for involvement along the care pathway from the point at which the decision is made that the patient requires vascular access surgery.

  3. Running a hospital patient safety campaign: a qualitative study

    PubMed Central

    Ozieranski, Piotr; Robins, Victoria; Minion, Joel; Willars, Janet; Wright, John; Weaver, Simon; Martin, Graham P.; Woods, Mary Dixon

    2017-01-01

    Purpose Research on patient safety campaigns has mostly concentrated on large-scale multi-organisation efforts, yet locally led improvement is increasingly promoted. The purpose of this paper is to characterise the design and implementation of an internal patient safety campaign at a large acute National Health Service hospital trust with a view to understanding how to optimise such campaigns. Design/methodology/approach The authors conducted a qualitative study of a campaign that sought to achieve 12 patient safety goals. The authors interviewed 19 managers and 45 frontline staff, supplemented by 56 hours of non-participant observation. Data analysis was based on the constant comparative method. Findings The campaign was motivated by senior managers’ commitment to patient safety improvement, a series of serious untoward incidents, and a history of campaign-style initiatives at the trust. While the campaign succeeded in generating enthusiasm and focus among managers and some frontline staff, it encountered three challenges. First, though many staff at the sharp end were aware of the campaign, their knowledge, and acceptance of its content, rationale, and relevance for distinct clinical areas were variable. Second, the mechanisms of change, albeit effective in creating focus, may have been too limited. Third, many saw the tempo of the campaign as too rapid. Overall, the campaign enjoyed some success in raising the profile of patient safety. However, its ability to promote change was mixed, and progress was difficult to evidence because of lack of reliable measurement. Originality/value The study shows that single-organisation campaigns may help in raising the profile of patient safety. The authors offer important lessons for the successful running of such campaigns. PMID:25241600

  4. [Safe patient care: safety culture and risk management in otorhinolaryngology].

    PubMed

    St Pierre, M

    2013-04-01

    Safety culture is positioned at the heart of an organisation's vulnerability to error because of its role in framing organizational awareness to risk and in providing and sustaining effective strategies of risk management. Safety related attitudes of leadership and management play a crucial role in the development of a mature safety culture ("top-down process"). A type marker for organizational culture and thus a predictor for an organizations maturity in respect to safety is information flow and in particular an organization's general way of coping with information that suggests anomaly. As all values and beliefs, relationships, learning, and other aspects of organizational safety culture are about sharing and processing information, safety culture has been termed "informed culture". An informed culture is free of blame and open for information provided by incidents. "Incident reporting systems" are the backbone of a reporting culture, where good information flow is likely to support and encourage other kinds of cooperative behavior, such as problem solving, innovation, and inter-departmental bridging. Another facet of an informed culture is the free flow of information during perioperative patient care. The World Health Organisation's "safe surgery checklist" is the most prevalent example of a standardized information exchange aimed at preventing patient harm due to information deficit. In routine tasks mandatory standard operating procedures have gained widespread acceptance in guaranteeing the highest possible process quality.Technical and non-technical skills of healthcare professionals are the decisive human resource for an efficient and safe delivery of patient care and the avoidance of errors. The systematic enhancement of staff qualification by providing training opportunities can be a major investment in patient safety. In recent years several otorhinolaryngology departments have started to incorporate simulation based team trainings into their curriculum.

  5. Patient-Reported Safety Information: A Renaissance of Pharmacovigilance?

    PubMed

    Härmark, Linda; Raine, June; Leufkens, Hubert; Edwards, I Ralph; Moretti, Ugo; Sarinic, Viola Macolic; Kant, Agnes

    2016-10-01

    The role of patients as key contributors in pharmacovigilance was acknowledged in the new EU pharmacovigilance legislation. This contains several efforts to increase the involvement of the general public, including making patient adverse drug reaction (ADR) reporting systems mandatory. Three years have passed since the legislation was introduced and the key question is: does pharmacovigilance yet make optimal use of patient-reported safety information? Independent research has shown beyond doubt that patients make an important contribution to pharmacovigilance signal detection. Patient reports provide first-hand information about the suspected ADR and the circumstances under which it occurred, including medication errors, quality failures, and 'near misses'. Patient-reported safety information leads to a better understanding of the patient's experiences of the ADR. Patients are better at explaining the nature, personal significance and consequences of ADRs than healthcare professionals' reports on similar associations and they give more detailed information regarding quality of life including psychological effects and effects on everyday tasks. Current methods used in pharmacovigilance need to optimise use of the information reported from patients. To make the most of information from patients, the systems we use for collecting, coding and recording patient-reported information and the methodologies applied for signal detection and assessment need to be further developed, such as a patient-specific form, development of a severity grading and evolution of the database structure and the signal detection methods applied. It is time for a renaissance of pharmacovigilance.

  6. Ten years after the IOM report: Engaging residents in quality and patient safety by creating a House Staff Quality Council.

    PubMed

    Fleischut, Peter M; Evans, Adam S; Nugent, William C; Faggiani, Susan L; Lazar, Eliot J; Liebowitz, Richard S; Forese, Laura L; Kerr, Gregory E

    2011-01-01

    Ten years after the 1999 Institute of Medicine report, it is clear that despite significant progress, much remains to be done to improve quality and patient safety (QPS). Recognizing the critical role of postgraduate trainees, an innovative approach was developed at New York-Presbyterian Hospital, Weill Cornell Medical Center to engage residents in QPS by creating a Housestaff Quality Council (HQC). HQC leaders and representatives from each clinical department communicate and partner regularly with hospital administration and other key departments to address interdisciplinary quality improvement (QI). In support of the mission to improve patient care and safety, QI initiatives included attaining greater than 90% compliance with medication reconciliation and reduction in the use of paper laboratory orders by more than 70%. A patient safety awareness campaign is expected to evolve into a transparent environment where house staff can openly discuss patient safety issues to improve the quality of care.

  7. Role of relatives of ethnic minority patients in patient safety in hospital care: a qualitative study

    PubMed Central

    van Rosse, Floor; Suurmond, Jeanine; Wagner, Cordula; de Bruijne, Martine; Essink-Bot, Marie-Louise

    2016-01-01

    Objective Relatives of ethnic minority patients often play an important role in the care process during hospitalisation. Our objective was to analyse the role of these relatives in relation to the safety of patients during hospital care. Setting Four large urban hospitals with an ethnic diverse patient population. Participants On hospital admission of ethnic minority patients, 20 cases were purposively sampled in which relatives were observed to play a role in the care process. Outcome measures We used documents (patient records) and added eight cases with qualitative interviews with healthcare providers, patients and/or their relatives to investigate the relation between the role of relatives and patient safety. An inductive approach followed by selective coding was used to analyse the data. Results Besides giving social support, family members took on themselves the role of the interpreter, the role of substitutes of the patient and the role of care provider. The taking over of these roles can have positive and negative effects on patient safety. Conclusions When family members take over various roles during hospitalisation of a relative, this can lead to a safety risk and a safety protection for the patient involved. Although healthcare providers should not hand over their responsibilities to the relatives of patients, optimising collaboration with relatives who are willing to take part in the care process may improve patient safety. PMID:27056588

  8. How Hispanic Patients Address Ambiguous versus Unambiguous Bias in the Doctor's Office

    PubMed Central

    Bean, Meghan G.; Covarrubias, Rebecca; Stone, Jeff

    2014-01-01

    Two studies examined Hispanic individuals’ preferences for using ten different bias reduction strategies when interacting with a doctor whose beliefs about their group were either ambiguous or clearly biased. Consistent with predictions, participants who imagined interacting with a doctor whose beliefs were ambiguous preferred strategies that facilitate positive doctor-patient interactions, whereas participants whose doctor explicitly endorsed negative stereotypes about their group preferred strategies that address stereotype content. The results also revealed that, regardless of whether the doctor's beliefs were ambiguous or clearly biased, stigma consciousness predicted participants’ preferences for using strategies that address stereotype content. These findings suggest that both doctors’ behavior and individual-level factors influence how minority individuals choose to behave in a healthcare setting. PMID:25395691

  9. Safety coaches in radiology: decreasing human error and minimizing patient harm.

    PubMed

    Dickerson, Julie M; Koch, Bernadette L; Adams, Janet M; Goodfriend, Martha A; Donnelly, Lane F

    2010-09-01

    Successful programs to improve patient safety require a component aimed at improving safety culture and environment, resulting in a reduced number of human errors that could lead to patient harm. Safety coaching provides peer accountability. It involves observing for safety behaviors and use of error prevention techniques and provides immediate feedback. For more than a decade, behavior-based safety coaching has been a successful strategy for reducing error within the context of occupational safety in industry. We describe the use of safety coaches in radiology. Safety coaches are an important component of our comprehensive patient safety program.

  10. Patient safety in emergency airway management and rapid sequence intubation: metaphorical lessons from skydiving.

    PubMed

    Levitan, Richard M

    2003-07-01

    Concern about patient safety and failed rapid sequence intubation has led to an increased awareness of potentially difficult laryngoscopy situations and algorithms promoting techniques in awake patients. Given the low overall incidence of failed laryngoscopy, however, prediction of difficult laryngoscopy has poor positive predictive value and uncertain clinical utility, especially in emergency settings. Non-rapid sequence intubation approaches have comparatively lower chances of intubation success, require more time, and are associated with more complications. As a specialty, emergency medicine has adopted rapid sequence intubation as the mainstay of emergency airway treatment for many appropriate reasons; the problem that must be addressed is how patient safety can be ensured while what is an inherently dangerous procedure is performed. A novel way to conceptualize patient risk and safety issues in rapid sequence intubation is to examine how inherent risk is managed in skydiving. Metaphorical lessons from skydiving that are applicable to rapid sequence intubation include (1) a redundancy of safety; (2) a methodic approach to primary chute deployment; (3) use of backup chutes that are fast, simple, and easy to deploy; (4) attention to monitoring; and (5) equipment vigilance. This article reviews how each of these lessons apply metaphorically to rapid sequence intubation, wherein the primary chute is laryngoscopy, the backup chute is rescue ventilation, and monitoring involves pulse oximetry.

  11. Evaluating the Effectiveness of an Educational Intervention to Improve the Patient Safety Attitudes of Intern Pharmacists

    PubMed Central

    Fois, Romano A.; McLachlan, Andrew J.; Chen, Timothy F.

    2017-01-01

    Objective. To evaluate the effectiveness of a face-to-face educational intervention in improving the patient safety attitudes of intern pharmacists. Methods. A patient safety education program was delivered to intern pharmacists undertaking The University of Sydney Intern Training Program in 2014. Their patient safety attitudes were evaluated immediately prior to, immediately after, and three-months post-intervention. Underlying attitudinal factors were identified using exploratory factor analysis. Changes in factor scores were examined using analysis of variance. Results. Of the 120 interns enrolled, 95 (78.7%) completed all three surveys. Four underlying attitudinal factors were identified: attitudes towards addressing errors, questioning behaviors, blaming individuals, and reporting errors. Improvements in all attitudinal factors were evident immediately after the intervention. However, only improvements in attitudes towards blaming individuals involved in errors were sustained at three months post-intervention. Conclusion. The educational intervention was associated with short-term improvements in pharmacist interns’ patient safety attitudes. However, other factors likely influenced their attitudes in the longer term. PMID:28289295

  12. The importance of the patient voice in vaccination and vaccine safety-are we listening?

    PubMed

    Holt, D; Bouder, F; Elemuwa, C; Gaedicke, G; Khamesipour, A; Kisler, B; Kochhar, S; Kutalek, R; Maurer, W; Obermeier, P; Seeber, L; Trusko, B; Gould, S; Rath, B

    2016-12-01

    Much has been written about the patient-physician relationship over the years. This relationship is essential in maintaining trust in the complex arena of modern diagnostic techniques, treatment and prevention, including vaccines and vaccine safety. However, a great deal of this material was written from the viewpoint of clinicians and academics. The patient voice may be positive or negative, fragmented or complex. Information sources are weighed and treated differently, according to the value system and risk perceptions of the individual. In post-trust societies, when people have less confidence in health authorities, communication needs to be more than a paternalistic top-down process. Notions of empowerment and individual patient choice are becoming crucial in medical care. The 'voice of the patient', which includes healthy individuals receiving vaccines, needs to be heard, considered and addressed. With respect to childhood immunizations, this will be the voice of the parent or caregiver. The key to addressing any concerns could be to listen more and to develop a communication style that is trust-based and science-informed. Regulatory agencies are encouraging clinical and patient-reported outcomes research under the umbrella of personalized medicine, and this is an important step forward. This paper attempts to reflect the paradigm shift towards increasing attention to the patient voice in vaccination and vaccine safety.

  13. 76 FR 79192 - Patient Safety Organizations: Voluntary Relinquishment From the Georgia Hospital Association...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-12-21

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary... Organization (GHA-PSO) AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice of... Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety...

  14. Public hospital palliative social work: addressing patient cultural diversity and psychosocial needs.

    PubMed

    Parrish, Monique; Cárdenas, Yvette; Epperhart, Regina; Hernandez, Jose; Ruiz, Susana; Russell, Linda; Soriano, Karolina; Thornberry, Kathryn

    2012-01-01

    Through creative practice innovations and a wide range of professional competencies, social work has contributed substantively to the development of the palliative care field (Harper, 2011 ). As the field continues to grow and evolve, new opportunities are emerging to profile palliative social work in diverse health care settings. A statewide initiative to spread palliative care in California's public hospitals provided just such an opportunity. Palliative social workers from six public hospitals participating in the initiative formed a group to discuss palliative social work in this unique hospital setting. This article highlights the group's insights and experiences as they address the significant cultural diversity and psychosocial needs of public hospital patients receiving palliative care.

  15. Hospital Nurses' Work Environment Characteristics and Patient Safety Outcomes.

    PubMed

    Lee, Seung Eun; Scott, Linda D

    2016-08-01

    This integrative literature review assesses the relationship between hospital nurses' work environment characteristics and patient safety outcomes and recommends directions for future research based on examination of the literature. Using an electronic search of five databases, 18 studies published in English between 1999 and 2016 were identified for review. All but one study used a cross-sectional design, and only four used a conceptual/theoretical framework to guide the research. No definition of work environment was provided in most studies. Differing variables and instruments were used to measure patient outcomes, and findings regarding the effects of work environment on patient outcomes were inconsistent. To clarify the relationship between nurses' work environment characteristics and patient safety outcomes, researchers should consider using a longitudinal study design, using a theoretical foundation, and providing clear operational definitions of concepts. Moreover, given the inconsistent findings of previous studies, they should choose their measurement methodologies with care.

  16. Cardiac magnetic resonance imaging: patient safety considerations.

    PubMed

    Giroletti, Elio; Corbucci, Giorgio

    Magnetic Resonance Imaging (MRI) is widely used in medicine. In cardiology, it is used to assess congenital or acquired diseases of the heat: and large vessels. Unless proper precautions are taken, it is generally advisable to avoid using this technique in patients with implanted electronic stimulators, such as pacemakers and defibrillators, on account of the potential risk of inducing electrical currents on the endocardial catheters, since these currents might stimulate the heart at a high frequency, thereby triggering dangerous arrhythmias. In addition to providing some basic information on pacemakers, defibrillators and MRI, and on the possible physical phenomena that may produce harmful effects, the present review examines the indications given in the literature, with particular reference to coronary stents, artificial heart valves and implantable cardiac stimulators.

  17. The Stories Clinicians Tell: Achieving High Reliability and Improving Patient Safety

    PubMed Central

    Cohen, Daniel L; Stewart, Kevin O

    2016-01-01

    The patient safety movement has been deeply affected by the stories patients have shared that have identified numerous opportunities for improvements in safety. These stories have identified system and/or human inefficiencies or dysfunctions, possibly even failures, often resulting in patient harm. Although patients’ stories tell us much, less commonly heard are the stories of clinicians and how their personal observations regarding the environments they work in and the circumstances and pressures under which they work may degrade patient safety and lead to harm. If the health care industry is to function like a high-reliability industry, to improve its processes and achieve the outcomes that patients rightly deserve, then leaders and managers must seek and value input from those on the front lines—both clinicians and patients. Stories from clinicians provided in this article address themes that include incident identification, disclosure and transparency, just culture, the impact of clinical workload pressures, human factors liabilities, clinicians as secondary victims, the impact of disruptive and punitive behaviors, factors affecting professional morale, and personal failings. PMID:26580146

  18. Medication safety.

    PubMed

    Keohane, Carol A; Bates, David W

    2008-03-01

    Patient safety is a state of mind, not a technology. The technologies used in the medical setting represent tools that must be properly designed, used well, and assessed on an on-going basis. Moreover, in all settings, building a culture of safety is pivotal for improving safety, and many nontechnologic approaches, such as medication reconciliation and teaching patients about their medications, are also essential. This article addresses the topic of medication safety and examines specific strategies being used to decrease the incidence of medication errors across various clinical settings.

  19. Safety of rasagiline in elderly patients with Parkinson disease.

    PubMed

    Goetz, C G; Schwid, S R; Eberly, S W; Oakes, D; Shoulson, I

    2006-05-09

    The authors examined age effects on adverse events from two randomized, controlled trials of rasagiline, comparing younger (younger than 70 years) and older (70 years and older) subjects. Older patients were more prone to serious adverse effects than younger patients, but there was no statistical interaction between age and rasagiline exposure. This absence of an age-rasagiline interaction suggests that rasagiline does not require special safety precautions for elderly subjects with Parkinson disease.

  20. Health IT for Patient Safety and Improving the Safety of Health IT.

    PubMed

    Magrabi, Farah; Ong, Mei-Sing; Coiera, Enrico

    2016-01-01

    Alongside their benefits health IT applications can pose new risks to patient safety. Problems with IT have been linked to many different types of clinical errors including prescribing and administration of medications; as well as wrong-patient, wrong-site errors, and delays in procedures. There is also growing concern about the risks of data breach and cyber-security. IT-related clinical errors have their origins in processes undertaken to design, build, implement and use software systems in a broader sociotechnical context. Safety can be improved with greater standardization of clinical software and by improving the quality of processes at different points in the technology life cycle, spanning design, build, implementation and use in clinical settings. Oversight processes can be set up at a regional or national level to ensure that clinical software systems meet specific standards. Certification and regulation are two mechanisms to improve oversight. In the absence of clear standards, guidelines are useful to promote safe design and implementation practices. Processes to identify and mitigate hazards can be formalised via a safety management system. Minimizing new patient safety risks is critical to realizing the benefits of IT.

  1. Addressing the access problem for patients with serious mental illness who require tertiary medical care.

    PubMed

    Hensel, Jennifer M; Flint, Alastair J

    2015-02-01

    There is evidence to suggest that people with serious mental illness (SMI) have lower access to tertiary care than patients without SMI, particularly when care is complex. Barriers are present at the level of the individual, providers, and the health care system. High levels of co-morbidity and the associated health care costs, along with a growing focus on facilitating equal access to quality care for all, urges health care systems to address existing gaps. Some interventions have been successful at improving access to primary care for patients with SMI, but relatively little research has focused on access to complex interventions. This paper summarizes the scope of the problem regarding access to complex tertiary medical care among people with SMI. Barriers are discussed and potential solutions are proposed. Policies and programs must be developed, implemented, and evaluated to determine cost-effectiveness and impact on outcomes.

  2. The Impact of Information Culture on Patient Safety Outcomes

    PubMed Central

    Mikkonen, Santtu; Saranto, Kaija; Bates, David W.

    2017-01-01

    Summary Background An organization’s information culture and information management practices create conditions for processing patient information in hospitals. Information management incidents are failures that could lead to adverse events for the patient if they are not detected. Objectives To test a theoretical model that links information culture in acute care hospitals to information management incidents and patient safety outcomes. Methods Reason’s model for the stages of development of organizational accidents was applied. Study data were collected from a cross-sectional survey of 909 RNs who work in medical or surgical units at 32 acute care hospitals in Finland. Structural equation modeling was used to assess how well the hypothesized model fit the study data. Results Fit indices indicated a good fit for the model. In total, 18 of the 32 paths tested were statistically significant. Documentation errors had the strongest total effect on patient safety outcomes. Organizational guidance positively affected information availability and utilization of electronic patient records, whereas the latter had the strongest total effect on the reduction of information delays. Conclusions Patient safety outcomes are associated with information management incidents and information culture. Further, the dimensions of the information culture create work conditions that generate errors in hospitals.

  3. Enhancing patient safety: improving the patient handoff process through appreciative inquiry.

    PubMed

    Shendell-Falik, Nancy; Feinson, Michael; Mohr, Bernard J

    2007-02-01

    Patient transfers from one care giver to another are an area of high safety consequence, as is evident by many studies and the Joint Commission on Accreditation of Healthcare Organization's Patient Safety Goals. The authors describe how one hospital made measurable improvements in a patient handoff process by using an unconventional approach to change called appreciative inquiry. Rather than identifying the root causes of ineffective handoffs, appreciative inquiry was used to engage staff in identifying and building on their most effective handoff experiences.

  4. Learning from positively deviant wards to improve patient safety: an observational study protocol

    PubMed Central

    Baxter, Ruth; Taylor, Natalie; Kellar, Ian; Lawton, Rebecca

    2015-01-01

    Introduction Positive deviance is an asset-based approach to improvement which has recently been adopted to improve quality and safety within healthcare. The approach assumes that solutions to problems already exist within communities. Certain groups or individuals identify these solutions and succeed despite having the same resources as others. Within healthcare, positive deviance has previously been applied at individual or organisational levels to improve specific clinical outcomes or processes of care. This study explores whether the positive deviance approach can be applied to multidisciplinary ward teams to address the broad issue of patient safety among elderly patients. Methods and analysis Preliminary work analysed National Health Service (NHS) Safety Thermometer data from 34 elderly medical wards to identify 5 ‘positively deviant’ and 5 matched ‘comparison’ wards. Researchers are blinded to ward status. This protocol describes a multimethod, observational study which will (1) assess the concurrent validity of identifying positively deviant elderly medical wards using NHS Safety Thermometer data and (2) generate hypotheses about how positively deviant wards succeed. Patient and staff perceptions of safety will be assessed on each ward using validated surveys. Correlation and ranking analyses will explore whether this survey data aligns with the routinely collected NHS Safety Thermometer data. Staff focus groups and researcher fieldwork diaries will be completed and qualitative thematic content analysis will be used to generate hypotheses about the strategies, behaviours, team cultures and dynamics that facilitate the delivery of safe patient care. The acceptability and sustainability of strategies identified will also be explored. Ethics and dissemination The South East Scotland Research Ethics Committee 01 approved this study (reference: 14/SS/1085) and NHS Permissions were granted from all trusts. Findings will be published in peer

  5. Creating a culture of safety for safe patient handling.

    PubMed

    Stevens, Linda; Rees, Susan; Lamb, Karen V; Dalsing, Deborah

    2013-01-01

    Healthcare workers who handle patients have little guidance to help them identify when to use the existing equipment for moving patients. Manual lifting of patients and healthcare worker injuries continue despite equipment installation and training. The purpose of this project was to decrease the number and severity of healthcare worker injuries by implementing a culture of safety for safe patient handling. A multicomponent safe patient handling program was deployed on one inpatient unit at a Midwest academic acute care hospital. There was a 36% decrease in the number of patient handling injuries, a 71% reduction in the number of lost work days, and a 60% reduction in costs in 1 year related to patient handling injuries. The RN Satisfaction Survey question regarding having enough help to lift/move on last shift improved from 41% presurvey to 69% postsurvey.

  6. Teamwork and communication: an effective approach to patient safety.

    PubMed

    Mujumdar, Sandhya; Santos, Diana

    2014-01-01

    Teamwork and communication failures are leading causes of patient safety incidents in health care. Though health care providers must work in teams, they are not well-trained in teamwork and communication skills. Health care faces the problems of differences in communication styles, communication failures and poor teamwork. There is enough evidence in the literature to show that communication failure is detrimental to patient safety. It is estimated that 80% of serious medical errors worldwide take place because of miscommunication between medical providers. NUH recognizes that effective communication and teamwork are essential in the delivery of high quality safe patient care, especially in a complex organization. NUH is a good example, where there is a rich mix of nationalities and races, in staff and in patients, and there is a rapidly expanding care environment. NUH had to overcome these challenges by adopting a multi-pronged approach. The trials and tribulations of NUH in this journey were worthwhile as the patient safety climate survey scores improved over the years.

  7. [Healthcare-Associated Infection Control with Awareness of Patient Safety].

    PubMed

    Murakami, Nobuo

    2016-03-01

    In order to provide safe and secure medical care for patients, health care-associated infections (HAI) must not occur. HAI should be considered as incidents, and countermeasures should be viewed as a patient safety management itself. Healthcare-associated infection control (HAIC) is practiced by the infection control team (ICT), which is based on multidisciplinary cooperation. Team members have to recognize that it is the most important to make use of the expertise of each discipline. In addition, all members must try to respond quickly, to help the clinic staff. Visualized rapid information provision and sharing, environmental improvement, outbreak factor analysis, hand hygiene compliance rate improvement, proper antibiotic use (Antimicrobial Stewardship Program: ASP), and regional cooperation & leadership comprise the role of the ICT in the flagship hospital. Regarding this role, we present our hospital's efforts and the outcomes. In conclusion, for medical practice quality improvement, healthcare-associated infection control should be conducted thoroughly along with an awareness of patient safety.

  8. Surgical robotics for patient safety in the perioperative environment: realizing the promise.

    PubMed

    Fuji Lai; Louw, Deon

    2007-06-01

    Surgery is at a crossroads of complexity. However, there is a potential path toward patient safety. One such course is to leverage computer and robotic assist techniques in the reduction and interception of error in the perioperative environment. This white paper attempts to facilitate the road toward realizing that promise by outlining a research agenda. The paper will briefly review the current status of surgical robotics and summarize any conclusions that can be reached to date based on existing research. It will then lay out a roadmap for future research to determine how surgical robots should be optimally designed and integrated into the perioperative workflow and process. Successful movement down this path would involve focused efforts and multiagency collaboration to address the research priorities outlined, thereby realizing the full potential of surgical robotics to augment human capabilities, enhance task performance, extend the reach of surgical care, improve health care quality, and ultimately enhance patient safety.

  9. Streets ahead on safety: young people's participation in decision-making to address the European road injury 'epidemic'.

    PubMed

    Kimberlee, Richard

    2008-05-01

    This paper reports on Birmingham City Council's Streets Ahead on Safety project which aims to improve road safety and quality of life in an area of multiple deprivation where 87 000 people from largely Asian, immigrant backgrounds live. A third of residents are under 16 years old and 58% self-define their religion as Muslim. The area has a poor traffic accident record leading to high levels of killed or seriously injured children. Child accidental injury in Europe is reaching 'epidemic' proportions, requiring innovative, ameliorative approaches to redress. Existing UK school-based road safety initiatives rarely extend beyond the 'tokenistic', but this project endeavoured to encourage a highway authority, engineers and road safety officers to provide local young people with opportunities to participate in decision-making in the belief that the active engagement of young service users would lead to more effective and sustainable solutions to accident prevention. Embracing the city's ratification of the UN Convention on the Rights of the Child (1989), this project promoted young people's participation in decision-making around engineering plans for their local community. The project included 405 young people aged 9-11 years who conducted environmental audits, interactive road safety awareness and citizenship training, and engaged as decision-makers. Successful outcomes include increased knowledge of road and community safety issues, and the establishment of young people as stakeholders in the development of their own safety and active engagement with service providers in the development of engineering proposals. This paper highlights the potential dynamics of participation and the dilemmas it poses for relationships between service users and providers, and outlines some of the barriers confronted by young people in learning to be active participants.

  10. Addressing fear of crime in public space: gender differences in reaction to safety measures in train transit.

    PubMed

    Yavuz, Nilay; Welch, Eric W

    2010-01-01

    Research has identified several factors that affect fear of crime in public space. However, the extent to which gender moderates the effectiveness of fear-reducing measures has received little attention. Using data from the Chicago Transit Authority Customer Satisfaction Survey of 2003, this study aims to understand whether train transit security practices and service attributes affect men and women differently. Findings indicate that, while the presence of video cameras has a lower effect on women's feelings of safety compared with men, frequent and on-time service matters more to male passengers. Additionally, experience with safety-related problems affects women significantly more than men. Conclusions discuss the implications of the study for theory and gender-specific policies to improve perceptions of transit safety.

  11. Efforts to improve patient safety in large, capitated medical groups: description and conceptual model.

    PubMed

    Miller, Robert H; Bovbjerg, Randall R

    2002-06-01

    Medical care should be safer. Inpatient problems and solutions have received the most attention; this outpatient qualitative case study addresses a gap in knowledge. We describe safety improvements among large physician groups, model the key influences on their behavior, and identify beneficial public and private policies. All groups were trying to reduce medical injury, which was part of the sample design. The most commonly targeted problems are those that are similar across groups: shortcomings in diagnosis, abnormal tests follow-up, scope of practice and referral patterns, and continuity of care. Medical group innovators vary greatly, however, in implementation of improvements, that is, in the extent to which they implement process changes that identify events/problems, analyze and track incidents, decide how to change clinical and administrative practices, and monitor impacts of the changes. Our conceptual model identifies key determinants: (1) demand for safety comes from external factors: legal, market, and professional; (2) organizational responses depend on internal factors: group size, scope, and integration; leadership and governance; professional culture; information-system assets; and financial and intellectual capital. Further, safety is an aspect of quality (the same tools, decision making, interventions, and monitoring apply), and safety management benefits from prior efficiency management (similar skills and culture of innovation). Observed variation in even simple safeguards shows that existing safety incentives are too weak. Our model suggests that the biggest improvement would come from boosting the demand for quality and safety from both private and public larger group purchasers. Current policy relies too much on litigation and discipline, which have sometimes helped, but not solved, problems because they are inefficient, tend to drive needed information underground, and complicate needed cultural change. Patients' safety demand is also weak

  12. Efficacy and Safety of Fingolimod in an Unselected Patient Population

    PubMed Central

    Andelova, Michaela; Naegelin, Yvonne; Stippich, Christoph; Kappos, Ludwig; Lindberg, Raija L. P.; Sprenger, Till; Derfuss, Tobias

    2016-01-01

    Background Fingolimod is a first in class oral compound approved for the treatment of relapsing-remitting multiple sclerosis (RR-MS). The aim of this study was to evaluate clinical and neuroradiological responses to fingolimod as well as the safety and tolerability in RR-MS patients in clinical practice. In addition, a panel of pro-inflammatory serum cytokines was explored as potential biomarker for treatment response. Methods We conducted a retrospective, non-randomized, open-label, observational study in 105 patients with RR-MS and measured cytokines in longitudinal serum samples. Results Compared to the year before fingolimod start the annualized relapse rate was reduced by 44%. Also, the percentage of patients with a worsening of the EDSS decreased. Accordingly, the fraction of patients with no evidence of disease activity (no relapse, stable EDSS, no new active lesions in MRI) increased from 11% to 38%. The efficacy and safety were comparable between highly active patients or patients with relevant comorbidities and our general patient population. Conclusions The efficacy in reducing relapses was comparable to that observed in the phase III trials. In our cohort fingolimod was safe and efficacious irrespective of comorbidities and previous treatment. PMID:26734938

  13. Providing Palliative Care to Patients with Cancer: Addressing the Needs in Kenya

    PubMed Central

    Malloy, Pam; Boit, Juli; Tarus, Allison; Marete, Joyce; Ferrell, Betty; Ali, Zipporah

    2017-01-01

    Cancer is the third highest cause of death in Kenya, preceded by infectious and cardiovascular diseases, and in most cases, diagnosed in later stages. Nurses are the primary caregivers, assessing and managing these patients in the clinic, in inpatient settings, and in rural and remote communities. While cancer rates remain high, the burden to the patient, the caregiver, and society as a whole continues to rise. Kenya's poverty complicates cancer even further. Many Kenyans are unaware of cancer's signs and symptoms, and limited diagnostic and treatment centers are available. Despite these barriers, there is still hope and help for those in Kenya, who suffer from cancer. The World Health Organization has stated that palliative care is a basic human right and nurses providing this care in Kenya are making efforts to support cancer patients’ ongoing needs, in order to promote compassionate palliative care and prevent suffering. The purpose of this paper is to address the palliative care needs of patients with cancer in Kenya by providing education to nurses and influencing health-care policy and education at micro and macro levels. A case study weaved throughout will highlight these issues. PMID:28217729

  14. Safety Design Requirements for Active Hazard Mitigation Device (AHMD) Employed to Address Fast and Slow Cook-off Thermal Threats

    DTIC Science & Technology

    2014-12-18

    Hazard Mitigation Device (AHMD) Employed to Address Fast and Slow Cook-off Thermal Threats 5a. CONTRACT NUMBER 5b. GRANT NUMBER 5c. PROGRAM...environments. 15. SUBJECT TERMS Active Hazard Mitigation Device insensitive munitions fast cook-off slow...DESIGN REQUIREMENTS FOR ACTIVE HAZARD MITIGATION DEVICE (AHMD) EMPLOYED TO ADDRESS FAST AND SLOW COOK-OFF THERMAL THREATS DOD Fuze Engineering

  15. Medical Error Disclosure and Patient Safety: Legal Aspects

    PubMed Central

    Guillod, Olivier

    2013-01-01

    Reducing the number of preventable adverse events has become a public health issue. The paper discusses in which ways the law can contribute to that goal, especially by encouraging a culture of safety among healthcare professionals. It assesses the need or the usefulness to pass so-called disclosure laws and apology laws, to adopt mandatory but strictly confidential Critical Incidents Reporting Systems in hospitals, to change the fault-based system of medical liability or to amend the rules on criminal liability. The paper eventually calls for adding the law to the present agenda of patient safety. Significance for public health The extent of preventable adverse events and the correlative need to improve patient safety are recognized today as a public health issue. In order to lower the toll associated with preventable adverse events, the former culture of professionalism (based on the premise that a good physician doesn’t make mistakes) must be replaced by a culture of safety, which requires a multi-pronged approach that includes all the main stakeholders within the healthcare system. A number of legal reforms could help in prompting such a change. This contribution stresses the need to include legal aspects when trying to find appropriate responses to public health issues. PMID:25170502

  16. 49 CFR 244.13 - Subjects to be addressed in a Safety Integration Plan involving an amalgamation of operations.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... transaction: (a) Corporate culture. Each applicant shall: (1) Identify and describe differences for each safety-related area between the corporate cultures of the railroads involved in the transaction; (2) Describe how these cultures lead to different practices governing rail operations; and (3) Describe,...

  17. 49 CFR 244.13 - Subjects to be addressed in a Safety Integration Plan involving an amalgamation of operations.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... transaction: (a) Corporate culture. Each applicant shall: (1) Identify and describe differences for each safety-related area between the corporate cultures of the railroads involved in the transaction; (2) Describe how these cultures lead to different practices governing rail operations; and (3) Describe,...

  18. Nuclear safety

    NASA Technical Reports Server (NTRS)

    Buden, D.

    1991-01-01

    Topics dealing with nuclear safety are addressed which include the following: general safety requirements; safety design requirements; terrestrial safety; SP-100 Flight System key safety requirements; potential mission accidents and hazards; key safety features; ground operations; launch operations; flight operations; disposal; safety concerns; licensing; the nuclear engine for rocket vehicle application (NERVA) design philosophy; the NERVA flight safety program; and the NERVA safety plan.

  19. Patient Safety in the Context of Neonatal Intensive Care: Research and Educational Opportunities

    PubMed Central

    Raju, Tonse N. K.; Suresh, Gautham; Higgins, Rosemary D.

    2012-01-01

    Case reports and observational studies continue to report adverse events from medical errors. However, despite considerable attention to patient safety in the popular media, this topic is not a regular component of medical education, and much research needs to be carried out to understand the causes, consequences, and prevention of healthcare-related adverse events during neonatal intensive care. To address the knowledge gaps and to formulate a research and educational agenda in neonatology, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) invited a panel of experts to a workshop in August 2010. Patient safety issues discussed were: the reasons for errors, including systems design, working conditions, and worker fatigue; a need to develop a “culture” of patient safety; the role of electronic medical records, information technology, and simulators in reducing errors; error disclosure practices; medico-legal concerns; and educational needs. Specific neonatology-related topics discussed were: errors during resuscitation, mechanical ventilation, and performance of invasive procedures; medication errors including those associated with milk feedings; diagnostic errors; and misidentification of patients. This article provides an executive summary of the workshop. PMID:21386749

  20. Implementing Protocols to Improve Patient Safety in the Medical Imaging Department.

    PubMed

    Carrizales, Gwen; Clark, Kevin R

    2015-01-01

    Patient safety is a focal point in healthcare because of recent changes issued by CMS. Hospital reimbursement rates have fallen, and these reimbursement rates are governed by CMS mandates regarding patient safety procedures. Reimbursement changes are reflected in the National Patient Safety Goals (NPSGs) administered annually by The Joint Commission. Medical imaging departments have multiple areas of patient safety concerns including effective handoff communication, proper patient identification, and safe medication/contrast administration. This literature review examines those areas of patient safety within the medical imaging department and reveals the need for continued protocol and policy changes to keep patients safe.

  1. “Health Courts” and Accountability for Patient Safety

    PubMed Central

    Mello, Michelle M; Studdert, David M; Kachalia, Allen B; Brennan, Troyen A

    2006-01-01

    Proposals that medical malpractice claims be removed from the tort system and processed in an alternative system, known as administrative compensation or ‘health courts,’ attract considerable policy interest during malpractice ‘crises,’ including the current one. This article describes current proposals for the design of a health court system and the system's advantages for improving patient safety. Among these advantages are the cultivation of a culture of transparency regarding medical errors and the creation of mechanisms to gather and analyze data on medical injuries. The article discusses the experiences of foreign countries with administrative compensation systems for medical injury, including their use of claims data for research on patient safety; choices regarding the compensation system's relationship to physician disciplinary processes; and the proposed system's possible limitations. PMID:16953807

  2. Human Factors in Patient Safety as an Innovation

    PubMed Central

    Carayon, Pascale

    2010-01-01

    The use of Human Factors and Ergonomics (HFE) tools, methods, concepts and theories has been advocated by many experts and organizations to improve patient safety. To facilitate and support the spread of HFE knowledge and skills in health care and patient safety, we propose to conceptualize HFE as innovations whose diffusion, dissemination, implementation and sustainability need to be understood and specified. Using Greenhalgh et al. (2004) model of innovation, we identified various factors that can either hinder or facilitate the spread of HFE innovations in healthcare organizations. Barriers include lack of systems thinking, complexity of HFE innovations and lack of understanding about the benefits of HFE innovations. Positive impact of HFE interventions on task performance and the presence of local champions can facilitate the adoption, implementation and sustainability of HFE innovations. This analysis concludes with a series of recommendations for HFE professionals, researchers and educators. PMID:20106468

  3. Improving Patient Safety in Anesthesia: A Success Story?

    SciTech Connect

    Botney, Richard

    2008-05-01

    Anesthesia is necessary for surgery; however, it does not deliver any direct therapeutic benefit. The risks of anesthesia must therefore be as low as possible. Anesthesiology has been identified as a leader in improving patient safety. Anesthetic mortality has decreased, and in healthy patients can be as low as 1:250,000. Trends in anesthetic morbidity have not been as well defined, but it appears that the risk of injury is decreasing. Studies of error during anesthesia and Closed Claims studies have identified sources of risk and methods to reduce the risks associated with anesthesia. These include changes in technology, such as anesthetic delivery systems and monitors, the application of human factors, the use of simulation, and the establishment of reporting systems. A review of the important events in the past 50 years illustrates the many steps that have contributed to the improvements in anesthesia safety.

  4. Therapeutic risk management of the suicidal patient: safety planning.

    PubMed

    Matarazzo, Bridget B; Homaifar, Beeta Y; Wortzel, Hal S

    2014-05-01

    This column is the fourth in a series describing a model for therapeutic risk management of the suicidal patient. Previous columns presented an overview of the therapeutic risk management model, provided recommendations for how to augment risk assessment using structured assessments, and discussed the importance of risk stratification in terms of both severity and temporality. This final column in the series discusses the safety planning intervention as a critical component of therapeutic risk management of suicide risk. We first present concerns related to the relatively common practice of using no-suicide contracts to manage risk. We then present the safety planning intervention as an alternative approach and provide recommendations for how to use this innovative strategy to therapeutically mitigate risk in the suicidal patient.

  5. Innovative patient-centered skills training addressing challenging issues in cancer communications: Using patient's stories that teach.

    PubMed

    Bishop, Thomas W; Gorniewicz, James; Floyd, Michael; Tudiver, Fred; Odom, Amy; Zoppi, Kathy

    2016-05-01

    This workshop demonstrated the utility of a patient-centered web-based/digital Breaking Bad News communication training module designed to educate learners of various levels and disciplines. This training module is designed for independent, self-directed learning as well as group instruction. These interactive educational interventions are based upon video-recorded patient stories. Curriculum development was the result of an interdisciplinary, collaborative effort involving faculty from the East Tennessee State University (ETSU) Graduate Storytelling Program and the departments of Family and Internal Medicine at the James H. Quillen College of Medicine. The specific goals of the BBN training module are to assist learners in: (1) understanding a five-step patient-centered model that is based upon needs, preferences, and expectations of patients with cancer and (2) individualizing communication that is consistent with patient preferences in discussing emotions, informational detail, prognosis and timeline, and whether or not to discuss end-of-life issues. The pedagogical approach to the training module is to cycle through Emotional Engagement, Data, Modeled Practices, Adaptation Opportunities, and Feedback. The communication skills addressed are rooted in concepts found within the Reaching Common Ground communication training. A randomized control study investigating the effectiveness of the Breaking Bad News module found that medical students as well as resident physicians improved their communication skills as measured by an Objective Structured Clinical Examination. Four other similarly designed modules were also created: Living Through Treatment, Transitions: From Curable to Treatable/From Treatable to End-of-Life, Spirituality, and Family.

  6. Accidents waiting to happen: the contribution of latent conditions to patient safety

    PubMed Central

    Lowe, C M

    2006-01-01

    Poor design of elements in a healthcare system produce the latent conditions which result in patient safety incidents. A better understanding of these elements and specific healthcare design challenges will result in improved patient safety. PMID:17142613

  7. [Organisational responsibility versus individual responsibility: safety culture? About the relationship between patient safety and medical malpractice law].

    PubMed

    Hart, Dieter

    2009-01-01

    The contribution is concerned with the correlations between risk information, patient safety, responsibility and liability, in particular in terms of liability law. These correlations have an impact on safety culture in healthcare, which can be evaluated positively if--in addition to good quality of medical care--as many sources of error as possible can be identified, analysed, and minimised or eliminated by corresponding measures (safety or risk management). Liability influences the conduct of individuals and enterprises; safety is (probably) also a function of liability; this should also apply to safety culture. The standard of safety culture does not only depend on individual liability for damages, but first of all on strict enterprise liability (system responsibility) and its preventive effects. Patient safety through quality and risk management is therefore also an organisational programme of considerable relevance in terms of liability law.

  8. A Checklist to Improve Patient Safety in Interventional Radiology

    SciTech Connect

    Koetser, Inge C. J.; Vries, Eefje N. de; Delden, Otto M. van; Smorenburg, Susanne M.; Boermeester, Marja A.; Lienden, Krijn P. van

    2013-04-15

    To develop a specific RADiological Patient Safety System (RADPASS) checklist for interventional radiology and to assess the effect of this checklist on health care processes of radiological interventions. On the basis of available literature and expert opinion, a prototype checklist was developed. The checklist was adapted on the basis of observation of daily practice in a tertiary referral centre and evaluation by users. To assess the effect of RADPASS, in a series of radiological interventions, all deviations from optimal care were registered before and after implementation of the checklist. In addition, the checklist and its use were evaluated by interviewing all users. The RADPASS checklist has two parts: A (Planning and Preparation) and B (Procedure). The latter part comprises checks just before starting a procedure (B1) and checks concerning the postprocedural care immediately after completion of the procedure (B2). Two cohorts of, respectively, 94 and 101 radiological interventions were observed; the mean percentage of deviations of the optimal process per intervention decreased from 24 % before implementation to 5 % after implementation (p < 0.001). Postponements and cancellations of interventions decreased from 10 % before implementation to 0 % after implementation. Most users agreed that the checklist was user-friendly and increased patient safety awareness and efficiency. The first validated patient safety checklist for interventional radiology was developed. The use of the RADPASS checklist reduced deviations from the optimal process by three quarters and was associated with less procedure postponements.

  9. Dobutamine Stress Echocardiography Safety in Chagas Disease Patients

    PubMed Central

    Rassi, Daniela do Carmo; Vieira, Marcelo Luiz Campos; Furtado, Rogerio Gomes; Turco, Fabio de Paula; Melato, Luciano Henrique; Hotta, Viviane Tiemi; Nunes, Colandy Godoy de Oliveira; Rassi Jr., Luiz; Rassi, Salvador

    2017-01-01

    Background A few decades ago, patients with Chagas disease were predominantly rural workers, with a low risk profile for obstructive coronary artery disease (CAD). As urbanization has increased, they became exposed to the same risk factors for CAD of uninfected individuals. Dobutamine stress echocardiography (DSE) has proven to be an important tool in CAD diagnosis. Despite being a potentially arrhythmogenic method, it is safe for coronary patients without Chagas disease. For Chagas disease patients, however, the indication of DSE in clinical practice is uncertain, because of the arrhythmogenic potential of that heart disease. Objectives To assess DSE safety in Chagas disease patients with clinical suspicion of CAD, as well as the incidence of arrhythmias and adverse events during the exam. Methods Retrospective analysis of a database of patients referred for DSE from May/2012 to February/2015. This study assessed 205 consecutive patients with Chagas disease suspected of having CAD. All of them had their serology for Chagas disease confirmed. Results Their mean age was 64±10 years and most patients were females (65.4%). No patient had significant adverse events, such as acute myocardial infarction, ventricular fibrillation, asystole, stroke, cardiac rupture and death. Regarding arrhythmias, ventricular extrasystoles occurred in 48% of patients, and non-sustained ventricular tachycardia in 7.3%. Conclusion DSE proved to be safe in this population of Chagas disease patients, in which no potentially life-threatening outcome was found. PMID:28099588

  10. Creating a Culture of Patient Safety through Innovative Hospital Design

    DTIC Science & Technology

    2005-05-01

    did not, as a result of chance, prevention , or mitigation. Unfortunately, a small portion of errors do result in an “adverse event”—an injury ...error on patient safety. For example, a 1991 Harvard Medical Practice Study reported that 69 percent of injuries suffered by hospitalized patients in...New York State in 1984 were the result of errors, and nearly 14 percent of these injuries were fatal.2 In another study, 2.4 percent (2,539 out of

  11. Direct anticoagulants and nursing: an approach from patient's safety.

    PubMed

    Romero Ruiz, Adolfo; Romero-Arana, Adolfo; Gómez-Salgado, Juan

    In recent years, a new line of treatment for the prevention of stroke in non-valvular atrial fibrillation, the so-called direct anticoagulants or new anticoagulants has appeared. The proper management and follow-up of these patients is essential to minimize their side effects and ensure patient safety. In this article, a description of these drugs is given, analyzing their characteristics, functioning and interactions together with the most habitual nursing interventions, as well as a reflection on the implications for the practice.

  12. Lasers Aimed at Aircraft Cockpits: Background and Possible Options to Address the Threat to Aviation Safety and Security

    DTIC Science & Technology

    2005-01-26

    1 Van B. Nakagawara and Ronald W. Montgomery. Laser Pointers : Their Potential Affects on Vision and Aviation Safety. Federal Aviation...powerful at extended viewing distances. Because lasers remain powerful over large distances, a laser pointer can expose pilots to radiation levels above...airliner by aiming a handheld laser pointer into the cockpit is highly unlikely, there is concern that a military laser , such as the Chinese-made ZM-87 laser

  13. CT Radiation Dose Management: A Comprehensive Optimization Process for Improving Patient Safety.

    PubMed

    Parakh, Anushri; Kortesniemi, Mika; Schindera, Sebastian T

    2016-09-01

    Rising concerns of radiation exposure from computed tomography have caused various advances in dose reduction technologies. While proper justification and optimization of scans has been the main focus to address increasing doses, the value of dose management has been largely overlooked. The purpose of this article is to explain the importance of dose management, provide an overview of the available options for dose tracking, and discuss the importance of a dedicated dose team. The authors also describe how a digital radiation tracking software can be used for analyzing the big data on doses for auditing patient safety, scanner utilization, and productivity, all of which have enormous personal and institutional implications. (©) RSNA, 2016.

  14. The Anesthesia Patient Safety Foundation at 25: a pioneering success in safety, 25th anniversary provokes reflection, anticipation.

    PubMed

    Eichhorn, John H

    2012-04-01

    The Anesthesia Patient Safety Foundation (APSF) was created in 1985. Its founders coined the term "patient safety" in its modern public usage and created the very first patient safety organization, igniting a movement that is now universal in all of health care. Driven by the vision "that no patient shall be harmed by anesthesia," the APSF has worked tirelessly for more than a quarter century to promote safety education and communication through its widely read Newsletter, its programs, and its presentations. The APSF's extensive research grant program has supported a great many projects leading to key safety improvements and, in particular, was central in the development of high-fidelity mannequin simulation as a research and teaching tool. With its pioneering collaboration, the APSF is unique in incorporating the talents and resources of anesthesia professionals of all types, safety scientists, pharmaceutical and equipment manufacturers, regulators, liability insurance companies, and also surgeons. Specific alerts, campaigns, discussions, and projects have targeted a host of safety issues and dangers over the years, starting with minimal intraoperative monitoring in 1986 and all the way up to beach-chair position cerebral perfusion pressure, operating room medication errors, and the extremely popular DVD on operating room fire safety in 2010; the list is long and expansive. The APSF has served as a model and inspiration for subsequent patient safety organizations and has been recognized nationally as having a dramatic positive impact on the safety of anesthesia care. Recognizing that the work is not over, that systems, organizations, and equipment still at times fail, that basic preventable human errors still do sometimes occur, and that "production pressure" in anesthesia practice threatens past safety gains, the APSF is firmly committed and continues to work hard both on established tenets and new patient safety principles.

  15. Patient safety series: obstetric safety improvement and its reflection in reserved claims.

    PubMed

    Iverson, Ronald E; Heffner, Linda J

    2011-11-01

    In reviewing outcomes that are associated with the implementation of a series of labor and delivery patient safety efforts from 2004-2009, we requested data on the number of related professional liability claims that were reserved by our insurance companies that are established with the specific objective of financing risks that emanate from their parent group or groups. While we restructured the manner in which we give care, required training modules, and provided simulations to our providers, our legal risk continued to be monitored independently and in parallel. Retrospective review of the number of cases for which money was held in reserve for claims demonstrated a 20% decrease per year, which was adjusted for delivery volume, over this time period. We believe that the improved care that resulted from our safety projects has led to this decreased legal risk.

  16. Enhancing Patient Safety Using Clinical Nursing Data: A Pilot Study.

    PubMed

    Choi, Jeeyae; Choi, Jeungok E

    2016-01-01

    To enhance patient safety from falls, many hospital information systems have been implemented to collect clinical data from the bedside and have used the information to improve fall prevention care. However, most of them use administrative data not clinical nursing data. This necessitated the development of a web-based Nursing Practice and Research Information Management System (NPRIMS) that processes clinical nursing data to measure nurses' delivery of fall prevention care and its impact on patient outcomes. This pilot study developed computer algorithms based on a falls prevention protocol and programmed the prototype NPRIMS. It successfully measured the performance of nursing care delivered and its impact on patient outcomes using clinical nursing data from the study site. Results of the study revealed that NPRIMS has the potential to pinpoint components of nursing processes that are in need of improvement for preventing patient from falls.

  17. Patient safety and hydration in the care of older people.

    PubMed

    Burns, Julie

    2016-05-01

    Ensuring patients are adequately hydrated is a fundamental part of nursing care, however, it is clear from the literature that dehydration remains a significant problem in the NHS with implications for patient safety. The development of dehydration is often multifactorial and older age is an independent risk factor for the condition. However, the media often blame nursing staff for simply not giving patients enough to drink. This article discusses the scale of the problem in acute care settings and aims to raise awareness of the importance of hydration management and accurate documentation in nursing practice. It suggests that intentional hourly rounding may provide an opportunity for nurses to ensure older patients are prompted or assisted to take a drink.

  18. 78 FR 6819 - Patient Safety Organizations: Voluntary Relinquishment From the BREF PSO

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-01-31

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Relinquishment From the BREF PSO AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice of delisting. SUMMARY: The Patient Safety and Quality Improvement Act of 2005 (Patient Safety...

  19. Cultures for improving patient safety through learning: the role of teamwork*

    PubMed Central

    Firth-Cozens, J

    2001-01-01

    Improvements in patient safety result primarily from organisational and individual learning. This paper discusses the learning that can take place within organisations and the cultural change necessary to encourage it. It focuses on teams and team leaders as potentially powerful forces for bringing about the management of patient safety and better quality of care. Key Words: patient safety; teamwork; learning PMID:11700376

  20. 78 FR 70560 - Patient Safety Organizations: Voluntary Relinquishment From GE-PSO

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-11-26

    ... Quality Patient Safety Organizations: Voluntary Relinquishment From GE- PSO AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice of delisting. SUMMARY: The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109-41, 42 U.S.C. 299b-21-b-26, provides for...

  1. 77 FR 38294 - Patient Safety Organizations: Delisting for Cause for Medical Informatics

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-27

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Delisting for...: Notice of Delisting. SUMMARY: AHRQ has delisted Medical Informatics as a Patient Safety Organization (PSO... (Patient Safety Act) authorizes the listing of PSOs, which are entities or component organizations...

  2. 77 FR 42736 - Common Formats for Patient Safety Data Collection and Event Reporting

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-20

    ... Collection and Event Reporting AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice... patient safety events to Patient Safety Organizations (PSOs). The purpose of this notice is to announce... facilities, and other healthcare providers may assemble information regarding patient safety events...

  3. Lessons learnt from Dental Patient Safety Case Reports

    PubMed Central

    Obadan, Enihomo M.; Ramoni, Rachel B.; Kalenderian, Elsbeth

    2015-01-01

    Background Errors are commonplace in dentistry, it is therefore our imperative as dental professionals to intercept them before they lead to an adverse event, and/or mitigate their effects when an adverse event occurs. This requires a systematic approach at both the profession-level, encapsulated in the Agency for Healthcare Research and Quality’s Patient Safety Initiative structure, as well as at the practice-level, where Crew Resource Management is a tested paradigm. Supporting patient safety at both the dental practice and profession levels relies on understanding the types and causes of errors, an area in which little is known. Methods A retrospective review of dental adverse events reported in the literature was performed. Electronic bibliographic databases were searched and data were extracted on background characteristics, incident description, case characteristics, clinic setting where adverse event originated, phase of patient care that adverse event was detected, proximal cause, type of patient harm, degree of harm and recovery actions. Results 182 publications (containing 270 cases) were identified through our search. Delayed and unnecessary treatment/disease progression after misdiagnosis was the largest type of harm reported. 24.4% of reviewed cases were reported to have experienced permanent harm. One of every ten case reports reviewed (11.1%) reported that the adverse event resulted in the death of the affected patient. Conclusions Published case reports provide a window into understanding the nature and extent of dental adverse events, but for as much as the findings revealed about adverse events, they also identified the need for more broad-based contributions to our collective body of knowledge about adverse events in the dental office and their causes. Practical Implications Siloed and incomplete contributions to our understanding of adverse events in the dental office are threats to dental patients’ safety. PMID:25925524

  4. Preventable Errors in Organ Transplantation: An Emerging Patient Safety Issue?

    PubMed Central

    Ison, Michael G.; Holl, Jane L.; Ladner, Daniela

    2012-01-01

    Several widely publicized errors in transplantation including a death due ABO incompatibility, two HIV transmissions and two HCV transmissions have raised concerns about medical errors in organ transplantation. The root cause analysis of each of these events revealed preventable failures in the systems and processes of care as the underlying causes. In each event, no standardized system or redundant process was in place to mitigate the failures that led to the error. Additional system and process vulnerabilities such as poor clinician communication, erroneous data transcription and transmission were also identified. Organ transplantation, because it is highly complex, often stresses the systems and processes of care and, therefore, offers a unique opportunity to proactively identify vulnerabilities and potential failures. Initial steps have been taken to understand such issues through the OPTN/UNOS Operations and Safety Committee, the Disease Transmission Advisory Committee (DTAC), and the current A2ALL ancillary Safety Study. However, to effectively improve patient safety in organ transplantation, the development of a process for reporting of preventable errors that affords protection and the support of empiric research are critical. Further, the transplant community needs to embrace the implementation of evidence-based system and process improvements that will mitigate existing safety vulnerabilities. PMID:22703471

  5. Telemedicine to Promote Patient Safety: Use of Phone-Based Interactive Voice-Response System to Reduce Adverse Safety Events in Pre-dialysis CKD.

    PubMed

    Weiner, Shoshana; Fink, Jeffery C

    2017-01-01

    CKD patients have several features conferring on them a high risk of adverse safety events, which are defined as incidents with unintended harm related to processes of care or medications. These characteristics include impaired kidney function, polypharmacy, and frequent health system encounters. The consequences of such events in CKD can include new or prolonged hospitalization, accelerated kidney function loss, acute kidney injury, ESRD, and death. Health information technology administered via telemedicine presents opportunities for CKD patients to remotely communicate safety-related findings to providers for the purpose of improving their care. However, many CKD patients have limitations that hinder their use of telemedicine and access to the broad capabilities of health information technology. In this review, we summarize previous assessments of the pre-dialysis CKD populations' proficiency in using telemedicine modalities and describe the use of interactive voice-response system to gauge the safety phenotype of the CKD patient. We discuss the potential for expanded interactive voice-response system use in CKD to address the safety threats inherent to this population.

  6. Students' corner: using Te Tiriti O Waitangi to identify and address racism, and achieve cultural safety in nursing.

    PubMed

    Oda, Keiko; Rameka, Maria

    2012-12-01

    Racism is an idea and belief that some races are superior to others (Harris et al., 2006a). This belief justifies institutional and individual practices that create and reinforce oppressive systems, inequality among racial or ethnic groups, and this creates racial hierarchy in society (Harris et al., 2006a). Recent studies have emphasised the impact of racism on ethnic health inequality (Harris et al., 2006a). In this article we analyse and discuss how nurses can challenge and reduce racism at interpersonal and institutional levels, and improve Māori health outcomes by understanding and using cultural safety in nursing practice and understanding Te Tiriti O Waitangi.

  7. Efficacy and safety of Cerebrolysin in patients with hemorrhagic stroke

    PubMed Central

    Tiu, C; Moessler, H; Antochi, F; Muresanu, D; Popescu, BO; Novak, P

    2010-01-01

    The purpose of the study was to investigate the efficacy and safety of Cerebrolysin in patients with hemorrhagic stroke. The primary objective of this trial was to assess the clinical efficacy and safety of a 10–days course of therapy with a daily administration of Cerebrolysin (50 mL Ⅳ per day). The trial had to demonstrate that Cerebrolysin treatment is safe in hemorrhagic stroke. Methods: The study was performed as a prospective, randomized, double blind, placebo–controlled, parallel group study with 2 treatment groups. Efficacy measures were the Unified Neurological Stroke Scale, Barthel Index, and Syndrome Short Test. The duration of the trial was of 21 days for each patient. Out of 100 randomized patients, a total of 96 (96%) completed the study. Results: Overall, no statistically significant group effects were observed based on single average comparisons at the individual visits. It could be shown that the treatment of hemorrhagic stroke with Cerebrolysin is safe and well tolerated. Conclusion: In the changes of UNSS, BI and SST from baseline to day 21, the group differences are not statistically significant; however, the use of Cerebrolysin in hemorrhagic stroke is safe and well tolerated and studies with a larger sample size may provide statistical evidence of Cerebrolysin's efficacy in patients with hemorrhagic stroke. PMID:20968198

  8. Teaching patient safety in the medical undergraduate program at the Universidade Federal de São Paulo

    PubMed Central

    Bohomol, Elena; Cunha, Isabel Cristina Kowal Olm

    2015-01-01

    Objective To analyze the Educational Project of the undergraduate medical course to verify what is taught regarding Patient Safety and to enable reflections on the educational practice. Methods A descriptive study, using document research as strategy. The document of investigation was the Educational Project of the medical course, in 2006, at the Escola Paulista de Medicina of the Universidade Federal de São Paulo. The theoretical framework adopted was the Multi-Professional Patient Safety Curriculum Guide of the World Health Organization, which led to the preparation of a list with 153 tracking terms. Results We identified 65 syllabus units in the Educational Project of the course, in which 40 (61.5%) addressed topics related to Patient Safety. Themes on the topic “Infection prevention and control” were found in 19 (47.5%) units and teaching of “Interaction with patients and caregivers” in 12 (32.5%); however content related to “Learning from errors to prevent harm” were not found. None of the framework topics had their proposed themes entirely taught during the period of education of the future physicians. Conclusion Patient safety is taught in a fragmented manner, which values clinical skills such as the diagnosis and treatment of diseases, post-treatment, surgical procedures, and follow-up. Since it is a recent movement, the teaching of patient safety confronts informative proposals based on traditional structures centered on subjects and on specific education, and it is still poorly valued. PMID:25993062

  9. An epistemology of patient safety research: a framework for study design and interpretation. Part 3. End points and measurement.

    PubMed

    Brown, C; Hofer, T; Johal, A; Thomson, R; Nicholl, J; Franklin, B D; Lilford, R J

    2008-06-01

    This article builds on the previous two articles in this series, which focused on an evaluation framework and study designs for patient safety research. The current article focuses on what to measure as evidence of safety and how these measurements can be undertaken. It considers four different end points, highlighting their methodological advantages and disadvantages: patient outcomes, fidelity, intervening variables and clinical error. The choice of end point depends on the nature of the intervention being evaluated and the patient safety problem it has been designed to address. This paper also discusses the different methods of measuring error, reviewing best practice and paying particular attention to case note review. Two key issues with any method of data collection are ensuring construct validity and reliability. Since no end point or method of data collection is infallible, the present authors advocate the use of multiple end points and methods where feasible.

  10. [Concept for a National Implant Registry to Improve Patient Safety].

    PubMed

    Prantl, L; von Fritschen, U; Liebau, J; von Hassel, J; Baur, E M; Vogt, P M; Giunta, R E; Horch, R E

    2016-12-01

    Since the introduction of silicone implants, several events have led to considerable uncertainty among the patients, public, and users. So far, however, the necessary steps to significantly improving patient safety have not been taken in any of these cases. Requiring stricter approvals for medical devices, improving monitoring by the regulatory authorities and the revision of the Medical Devices Directive are all initial steps in the right direction towards a change in policy, but are insufficient as an early warning system. After the introduction of registers was announced in the coalition agreement, the German Society of Plastic, Aesthetic and Reconstructive Surgeons (DGPRÄC), in close consultation with the Ministry of Health, has developed a concept which is presented here. The need for a uniform and legally binding central register for breast implants is fully supported by the entire medical profession. According to the concept presented by the DGPRÄC, three data qualities would be applicable: Safety data (mandatory), physician information (voluntary) and research data (optional, except if safety related). The public authorities are creating a unified, secure entry portal for all professional associations concerned. This register is based with the professional associations, and from there the mandatory security data will be forwarded to the public authorities. Decoding of the identity of the patient and doctor would only occur in specifically defined emergency situations such as product recalls. Automated tools in the security database provide early detection of problems, so that rapid clarification is possible in consultation with the professional associations, manufacturers and possibly patients. This concept as proposed by the DGPRÄC has thus far been very positively received in all discussions between the various parties concerned.

  11. A prospective study of patient safety incidents in gastrointestinal endoscopy

    PubMed Central

    Matharoo, Manmeet; Haycock, Adam; Sevdalis, Nick; Thomas-Gibson, Siwan

    2017-01-01

    Background and study aims Medical error occurs frequently with significant morbidity and mortality. This study aime to assess the frequency and type of endoscopy patient safety incidents (PSIs). Patients and methods A prospective observational study of PSIs in routine diagnostic and therapeutic endoscopy was undertaken in a secondary and tertiary care center. Observations were undertaken within the endoscopy suite across pre-procedure, intra-procedure and post-procedure phases of care. Experienced (Consultant-level) and trainee endoscopists from medical, surgical, and nursing specialities were included. PSIs were defined as any safety issue that had the potential to or directly adversely affected patient care: PSIs included near misses, complications, adverse events and “never events”. PSIs were reviewed by an expert panel and categorized for severity and nature via expert consensus. Results One hundred and forty procedures (92 diagnostic, 48 therapeutic) over 37 lists (experienced operators n = 25, trainees n = 12) were analyzed. One hundred forty PSIs were identified (median 1 per procedure, range 0 – 7). Eighty-six PSIs (61 %) occurred in 48 therapeutic procedures. Zero PSIs were detected in 13 diagnostic procedures. 21 (15 %) PSIs were categorized as severe and 12 (9 %) had the potential to be “never events,” including patient misidentification and wrong procedure. Forty PSIs (28 %) were of intermediate severity and 78 (56 %) were minor. Oxygen monitoring PSIs occurred most frequently. Conclusion This is the first study documenting the range and frequency of PSIs in endoscopy. Although many errors are minor without immediate consequence, further work should identify whether prevention of such recurrent errors affects the incidence of severe errors, thus improving safety and quality. PMID:28191498

  12. [Infrastructure and adherence to hand hygiene: challenges to patient safety].

    PubMed

    Bathke, Janaína; de Cunico, Priscila Almeida; Maziero, Eliane Cristina Sanches; Cauduro, Fernanda Leticia Frates; Sarquis, Leila Maria Mansano; de Cruz, Elaine Drehmer Almeida

    2013-06-01

    Considering the importance of hands in the chain of transmission of microorganisms, this observational research investigated the material infrastructure and compliance of hand hygiene in an intensive care unit in the south of Brazil in 2010. The data was collected by direct non-participant observation and through the use of self-administered questionnaires to be completed by the 39 participants, which was analyzed with the assistance of the chi2 Test, descriptive statistics and quantitative discourse analysis. Although health professionals overestimate compliance rates, recognize the practice as relevant to the prevention of infection and refer there are no impeding factors, of the 1,277 opportunities observed, compliance was 26% and significantly lower before patient contact and the use of aseptic procedures than after patient contact: infrastructure was shown to be deficient. The results indicate risk to patient safety, and thus, the planning of corrective actions to promote hand washing is relevant.

  13. The Safety of Thoracentesis in Patients with Uncorrected Bleeding Risk

    PubMed Central

    Argento, A. Christine; Murphy, Terrence E.; Araujo, Katy L. B.; Pisani, Margaret A.

    2013-01-01

    Background: Thoracentesis is commonly performed to evaluate pleural effusions. Many medications (warfarin, heparin, clopidogrel) or physiological factors (elevated International Normalized Ratio [INR], thrombocytopenia, uremia) increase the risk for bleeding. Frequently these medications are withheld or transfusions are performed to normalize physiological parameters before a procedure. The safety of performing thoracentesis without correction of these bleeding risks has not been prospectively evaluated. Methods: This prospective observational cohort study enrolled 312 patients who underwent thoracentesis. All patients were evaluated for the presence of risk factors for bleeding. Hematocrit levels were obtained pre- and postprocedure, and the occurrence of postprocedural hemothorax was evaluated. Measurements and Main Results: Thoracenteses were performed in 312 patients, 42% of whom had a risk for bleeding. Elevated INR, secondary to liver disease or warfarin, and renal disease were the two most common etiologies for bleeding risk, although many patients had multiple potential bleeding risks. There was no significant difference in pre- and postprocedural hematocrit levels in patients with a bleeding risk when compared with patients with no bleeding risk. No patient developed a hemothorax as a result of the thoracentesis. Conclusions: This single-center, observational study suggests that thoracentesis may be safely performed without prior correction of coagulopathy, thrombocytopenia, or medication-induced bleeding risk. This may reduce the morbidity associated with transfusions or withholding of medications. PMID:23952852

  14. "Going solid": a model of system dynamics and consequences for patient safety

    PubMed Central

    Cook, R; Rasmussen, J

    2005-01-01

    

 Rather than being a static property of hospitals and other healthcare facilities, safety is dynamic and often on short time scales. In the past most healthcare delivery systems were loosely coupled—that is, activities and conditions in one part of the system had only limited effect on those elsewhere. Loose coupling allowed the system to buffer many conditions such as short term surges in demand. Modern management techniques and information systems have allowed facilities to reduce inefficiencies in operation. One side effect is the loss of buffers that previously accommodated demand surges. As a result, situations occur in which activities in one area of the hospital become critically dependent on seemingly insignificant events in seemingly distant areas. This tight coupling condition is called "going solid". Rasmussen's dynamic model of risk and safety can be used to formulate a model of patient safety dynamics that includes "going solid" and its consequences. Because the model addresses the dynamic aspects of safety, it is particularly suited to understanding current conditions in modern healthcare delivery and the way these conditions may lead to accidents. PMID:15805459

  15. The CCLM contribution to improvements in quality and patient safety.

    PubMed

    Plebani, Mario

    2013-01-01

    Clinical laboratories play an important role in improving patient care. The past decades have seen unbelievable, often unpredictable improvements in analytical performance. Although the seminal concept of the brain-to-brain laboratory loop has been described more than four decades ago, there is now a growing awareness about the importance of extra-analytical aspects in laboratory quality. According to this concept, all phases and activities of the testing cycle should be assessed, monitored and improved in order to decrease the total error rates thereby improving patients' safety. Clinical Chemistry and Laboratory Medicine (CCLM) not only has followed the shift in perception of quality in the discipline, but has been the catalyst for promoting a large debate on this topic, underlining the value of papers dealing with errors in clinical laboratories and possible remedies, as well as new approaches to the definition of quality in pre-, intra-, and post-analytical steps. The celebration of the 50th anniversary of the CCLM journal offers the opportunity to recall and mention some milestones in the approach to quality and patient safety and to inform our readers, as well as laboratory professionals, clinicians and all the stakeholders of the willingness of the journal to maintain quality issues as central to its interest even in the future.

  16. The disruptive orthopaedic surgeon: implications for patient safety and malpractice liability.

    PubMed

    Patel, Pranay; Robinson, Brooke S; Novicoff, Wendy M; Dunnington, Gary L; Brenner, Michael J; Saleh, Khaled J

    2011-11-02

    Disruptive physician behavior imperils patient safety, erodes the morale of other health care providers, and dramatically increases the risk of malpractice litigation. Increasing patient volume, decreasing physician reimbursement, malpractice litigation, elevated stress, and growing job dissatisfaction have been implicated in disruptive behavior, which has emerged as one of the major challenges in health care. Because the aging patient population relies increasingly on orthopaedic services to maintain quality of life, improving professionalism and eradicating disruptive behavior are urgent concerns in orthopaedic surgery. Although many steps have been taken by The Joint Commission to improve patient care and define disruptive behavior, there is further room for improvement by physicians. Barriers to eliminating disruptive behavior by orthopaedic surgeons include fear of retaliation, lack of awareness among the surgeon's peers, and financial factors. Surgeons have a duty to address patterns of negative peer behavior for the benefit of patient care. This manuscript addresses the causes and consequences of disruptive physician behavior as well as management strategies, especially in orthopaedic surgery.

  17. A comparison of inpatient glucose management guidelines: implications for patient safety and quality.

    PubMed

    Mathioudakis, Nestoras; Golden, Sherita Hill

    2015-03-01

    Inpatient glucose management guidelines and consensus statements play an important role in helping to keep hospitalized patients with diabetes and hyperglycemia safe and in optimizing the quality of their glycemic control. In this review article, we compare and contrast seven prominent US guidelines on recommended glycemic outcome measures and processes of care, with the goal of highlighting how variation among them might influence patient safety and quality. The outcome measures of interest include definitions of glucose abnormalities and glycemic targets. The relevant process measures include detection and documentation of diabetes/hyperglycemia, methods of and indications for insulin therapy, management of non-insulin agents, blood glucose monitoring, management of special situations (e.g., parenteral/enteral nutrition, glucocorticoids, surgery, insulin pumps), and appropriate transitions of care. In addition, we address elements of quality improvement, such as glycemic control program infrastructure, glucometrics, insulin safety, and professional education. While most of these guidelines align with respect to outcome measures such as glycemic targets, there is significant heterogeneity among process measures, which we propose might introduce variation or even confusion in clinical practice and possibly affect quality of care. Guideline-related factors, such as rigor of development, clarity, and presentation, may also affect provider trust in and adherence to guidelines. There is a need for high-quality research to address knowledge gaps in optimal glucose management practice approaches in the hospital setting.

  18. Efficacy, safety, and patient acceptability of the Essure™ procedure

    PubMed Central

    Lessard, Collette R; Hopkins, Matthew R

    2011-01-01

    The Essure™ system for permanent contraception was developed as a less invasive method of female sterilization. Placement of the Essure™ coil involves a hysteroscopic transcervical technique. This procedure can be done in a variety of settings and with a range of anesthetic options. More than eight years have passed since the US Food and Drug Administration approval of Essure™. Much research has been done to evaluate placement success, adverse outcomes, satisfaction, pain, and the contraceptive efficacy of the Essure™. The purpose of this review is to summarize the available literature regarding the efficacy, safety, and patient satisfaction with this new sterilization technique. PMID:21573052

  19. Enteral feeding pumps: efficacy, safety, and patient acceptability

    PubMed Central

    White, Helen; King, Linsey

    2014-01-01

    Enteral feeding is a long established practice across pediatric and adult populations, to enhance nutritional intake and prevent malnutrition. Despite recognition of the importance of nutrition within the modern health agenda, evaluation of the efficacy of how such feeds are delivered is more limited. The accuracy, safety, and consistency with which enteral feed pump systems dispense nutritional formulae are important determinants of their use and acceptability. Enteral feed pump safety has received increased interest in recent years as enteral pumps are used across hospital and home settings. Four areas of enteral feed pump safety have emerged: the consistent and accurate delivery of formula; the minimization of errors associated with tube misconnection; the impact of continuous feed delivery itself (via an enteral feed pump); and the chemical composition of the casing used in enteral feed pump manufacture. The daily use of pumps in delivery of enteral feeds in a home setting predominantly falls to the hands of parents and caregivers. Their understanding of the use and function of their pump is necessary to ensure appropriate, safe, and accurate delivery of enteral nutrition; their experience with this is important in informing clinicians and manufacturers of the emerging needs and requirements of this diverse patient population. The review highlights current practice and areas of concern and establishes our current knowledge in this field. PMID:25170284

  20. Enteral feeding pumps: efficacy, safety, and patient acceptability.

    PubMed

    White, Helen; King, Linsey

    2014-01-01

    Enteral feeding is a long established practice across pediatric and adult populations, to enhance nutritional intake and prevent malnutrition. Despite recognition of the importance of nutrition within the modern health agenda, evaluation of the efficacy of how such feeds are delivered is more limited. The accuracy, safety, and consistency with which enteral feed pump systems dispense nutritional formulae are important determinants of their use and acceptability. Enteral feed pump safety has received increased interest in recent years as enteral pumps are used across hospital and home settings. Four areas of enteral feed pump safety have emerged: the consistent and accurate delivery of formula; the minimization of errors associated with tube misconnection; the impact of continuous feed delivery itself (via an enteral feed pump); and the chemical composition of the casing used in enteral feed pump manufacture. The daily use of pumps in delivery of enteral feeds in a home setting predominantly falls to the hands of parents and caregivers. Their understanding of the use and function of their pump is necessary to ensure appropriate, safe, and accurate delivery of enteral nutrition; their experience with this is important in informing clinicians and manufacturers of the emerging needs and requirements of this diverse patient population. The review highlights current practice and areas of concern and establishes our current knowledge in this field.

  1. Addressing metabolite safety during first-in-man studies using ¹⁴C-labeled drug and accelerator mass spectrometry.

    PubMed

    Lappin, Graham; Seymour, Mark

    2010-07-01

    Active drug metabolites formed in humans but present in relatively low abundance in preclinical species can lead to unpredicted adverse effects during clinical use. The regulatory guidelines in recent years have therefore required that the metabolism of a drug be quantitatively compared between preclinical species and human at the earliest practicable stage of drug development. Amongst the variety of methods available, inclusion of low radioactive doses of ¹⁴C drug in first-in-man studies coupled to the sensitive analytical technology of accelerator MS (AMS) has found utility. Measurement of ¹⁴C by AMS allows for quantification of metabolites, even if their structures are unknown, and, when used in conjunction with LC-MS, can provide both quantitative and structural data. This review examines a typical approach to using AMS and associated analytical methods in addressing the regulatory guidelines and discusses a number of possible scenarios including the question of steady state.

  2. What Does a Hospital Survey on Patient Safety Reveal About Patient Safety Culture of Surgical Units Compared With That of Other Units?

    PubMed

    Shu, Qin; Cai, Miao; Tao, Hong-Bing; Cheng, Zhao-Hui; Chen, Jing; Hu, Yin-Huan; Li, Gang

    2015-07-01

    The objective of this study was to examine the strengths and weaknesses of surgical units as compared with other units, and to provide an opportunity to improve patient safety culture in surgical settings by suggesting targeted actions using Hospital Survey on Patient Safety Culture (HSOPSC) investigation.A Hospital Survey on Patient Safety questionnaire was conducted to physicians and nurses in a tertiary hospital in Shandong China. 12 patient safety culture dimensions and 2 outcome variables were measured.A total of 23.5% of respondents came from surgical units, and 76.5% worked in other units. The "overall perceptions of safety" (48.1% vs 40.4%, P < 0.001) and "frequency of events reported" (63.7% vs 60.7%, P = 0.001) of surgical units were higher than those of other units. However, the communication openness (38.7% vs 42.5%, P < 0.001) of surgical units was lower than in other units. Medical workers in surgical units reported more events than those in other units, and more respondents in the surgical units assess "patient safety grade" to be good/excellent. Three dimensions were considered as strengths, whereas 5 other dimensions were considered to be weaknesses in surgical units. Six dimensions have potential to aid in improving events reporting and patient safety grade. Appropriate working times will also contribute to ensuring patient safety. Medical staff with longer years of experience reported more events.Surgical units outperform the nonsurgical ones in overall perception of safety and the number of events reported but underperform in the openness of communication. Four strategies, namely deepening the understanding about patient safety of supervisors, narrowing the communication gap within and across clinical units, recruiting more workers, and employing the event reporting system and building a nonpunitive culture, are recommended to improve patient safety in surgical units in the context of 1 hospital.

  3. Patient safety in women's health care: a framework for progress.

    PubMed

    Gluck, Paul A

    2007-08-01

    Patient safety research is hampered by lack of a clear taxonomy and difficulty in detecting errors. Preventable adverse events occur in medicine because of human fallibility, complexity, system deficiencies and vulnerabilities in defensive barriers. To make medicine safer there needs to be a culture change, beginning with the leadership. Latent systems deficiencies must be identified and corrected before they cause harm. Defensive barriers can be improved to intercept errors before patients are harmed. Strategies include: (1) providing leadership at all levels; (2) respecting human limits in equipment and process design; (3) functioning collaboratively in a team model with mutual respect; (4) creating a learning environment where errors can be analyzed without fear of retribution; and (5) anticipating the unexpected with analysis of high-risk processes and well-designed contingency plans. The ideal of a 100% safe health-care system is unattainable, but there must be continual improvement.

  4. Patient safety climate strength: a concept that requires more attention

    PubMed Central

    Ginsburg, Liane; Gilin Oore, Debra

    2016-01-01

    Background When patient safety climate (PSC) surveys are used in healthcare, reporting typically focuses on PSC level (mean or per cent positive scores). This paper explores how an additional focus on PSC strength can enhance the utility of PSC survey data. Setting and participants 442 care providers from 24 emergency departments (EDs) across Canada. Methods We use anonymised data from the Can-PSCS PSC instrument collected in 2011 as part of the Qmentum accreditation programme. We examine differences in climate strength across EDs using the Rwg(j) and intraclass correlation coefficients measures of inter-rater agreement. Results Across the six survey dimensions, median Rwg(j) was sufficiently high to support shared climate perceptions (0.64–0.83), but varied widely across the 24 ED units. We provide an illustrative example showing vastly different climate strength (Rwg(j) range=0.17–0.86) for units with an equivalent level of PSC (eg, climate mean score=3). Conclusions Most PSC survey results focus solely on climate level. To facilitate improvement in PSC, we advocate a simple, holistic safety climate profile including three metrics: climate level (using mean or per cent positive climate scores), climate strength (using the Rwg(j), or SD as a proxy) and the shape of the distribution (using histograms to see the distribution of scores within units). In PSC research, we advocate paying attention to climate strength as an important variable in its own right. Focusing on PSC level and strength can further understanding of the extent to which PSC is a key variable in the domain of patient safety. PMID:26453636

  5. Application of Bow-tie methodology to improve patient safety.

    PubMed

    Abdi, Zhaleh; Ravaghi, Hamid; Abbasi, Mohsen; Delgoshaei, Bahram; Esfandiari, Somayeh

    2016-05-09

    Purpose - The purpose of this paper is to apply Bow-tie methodology, a proactive risk assessment technique based on systemic approach, for prospective analysis of the risks threatening patient safety in intensive care unit (ICU). Design/methodology/approach - Bow-tie methodology was used to manage clinical risks threatening patient safety by a multidisciplinary team in the ICU. The Bow-tie analysis was conducted on incidents related to high-alert medications, ventilator associated pneumonia, catheter-related blood stream infection, urinary tract infection, and unwanted extubation. Findings - In total, 48 potential adverse events were analysed. The causal factors were identified and classified into relevant categories. The number and effectiveness of existing preventive and protective barriers were examined for each potential adverse event. The adverse events were evaluated according to the risk criteria and a set of interventions were proposed with the aim of improving the existing barriers or implementing new barriers. A number of recommendations were implemented in the ICU, while considering their feasibility. Originality/value - The application of Bow-tie methodology led to practical recommendations to eliminate or control the hazards identified. It also contributed to better understanding of hazard prevention and protection required for safe operations in clinical settings.

  6. Caregivers' perception of drug administration safety for pediatric oncology patients.

    PubMed

    Harris, Nariman; Badr, Lina Kurdahi; Saab, Raya; Khalidi, Aziza

    2014-01-01

    Medication errors (MEs) are reported to be between 1.5% and 90% depending on many factors, such as type of the institution where data were collected and the method to identify the errors. More significantly, the risk for errors with potential for harm is 3 times higher for children, especially those receiving chemotherapy. Few studies have been published on averting such errors with children and none on how caregivers perceive their role in preventing such errors. The purpose of this study was to evaluate pediatric oncology patient's caregivers' perception of drug administration safety and their willingness to be involved in averting such errors. A cross-sectional design was used to study a nonrandomized sample of 100 caregivers of pediatric oncology patients. Ninety-six of the caregivers surveyed were well informed about the medications their children receive and were ready to participate in error prevention strategies. However, an underestimation of potential errors uncovered a high level of "trust" for the staff. Caregivers echoed their apprehension for being responsible for potential errors. Caregivers are a valuable resource to intercept medication errors. However, caregivers may be hesitant to actively communicate their fears with health professionals. Interventions that aim at encouraging caregivers to engage in the safety of their children are recommended.

  7. Efficacy and safety of methimazole ointment for patients with hyperthyroidism.

    PubMed

    Wu, Xi; Liu, Hong; Zhu, Xixing; Shen, Jun; Shi, Yongquan; Liu, Zhimin; Gu, Mingjun; Song, Zhimin

    2013-11-01

    Oral methimazole has been widely used to treat hyperthyroidism, but its usage is restricted by its adverse systemic effects. The aim of this study was to investigate the efficacy and safety of methimazole ointment for the treatment of hyperthyroidism. One hundred forty-four subjects with hyperthyroidism were initially enrolled. These patients were initially divided into two groups and given the following treatments for 12 weeks: patients in group A received 5% methimazole ointment applied to the skin around the thyroid and an oral placebo; and patients in group B received methimazole tablets and placebo ointment. One hundred thirty-one subjects were included in the final analysis. Therapeutic efficacy was assessed via the levels of free triiodothyronine and thyroxine in the serum and by biweekly monitoring of the symptoms of thyrotoxicosis. Adverse effects were recorded. Fifty-nine (89.40%) patients in group A and 57 (87.69%) patients in group B were euthyroid and experienced alleviation of thyrotoxicosis symptoms (complete control; p>0.05). The median times required to achieve complete control for the patients in the two groups were 6.5 weeks and 6.4 weeks for groups A and B, respectively (p>0.05). Systemic adverse effects (e.g., rash, liver dysfunction, leucopenia, etc.) were significantly less common in group A (1.5%) than in group B (12.3%; p<0.05). This study showed that methimazole ointment has a clinical efficacy similar to that of oral tablets, but methimazole ointment caused fewer systemic adverse effects in patients with hyperthyroidism.

  8. Patient safety in the rehabilitation of the adult with an amputation.

    PubMed

    Latlief, Gail; Elnitsky, Christine; Hart-Hughes, Stephanie; Phillips, Samuel L; Adams-Koss, Laurel; Kent, Robert; Highsmith, M Jason

    2012-05-01

    This article reviews and summarizes the literature on patient safety issues in the rehabilitation of adults with an amputation. Safety issues in the following areas are discussed; the prosthesis, falls, wound care, pain, and treatment of complex patients. Specific recommendations for further research and implementation strategies to prevent injury and improve safety are also provided. Communication between interdisciplinary team members and patient and caregiver education are crucial to executing a safe treatment plan. The multidisciplinary rehabilitation team members should feel comfortable discussing safety issues with patients and be able to recommend preventive approaches to patients as appropriate.

  9. 76 FR 71346 - Patient Safety Organizations: Voluntary Relinquishment From Peminic Inc. dba The Peminic-Greeley PSO

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-17

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary... relinquishment from Peminic Inc. dba The Peminic-Greeley PSO of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109-41, 42...

  10. Safety of robotic general surgery in elderly patients.

    PubMed

    Buchs, Nicolas C; Addeo, Pietro; Bianco, Francesco M; Ayloo, Subhashini; Elli, Enrique F; Giulianotti, Pier C

    2010-08-01

    As the life expectancy of people in Western countries continues to rise, so too does the number of elderly patients. In parallel, robotic surgery continues to gain increasing acceptance, allowing for more complex operations to be performed by minimally invasive approach and extending indications for surgery to this population. The aim of this study is to assess the safety of robotic general surgery in patients 70 years and older. From April 2007 to December 2009, patients 70 years and older, who underwent various robotic procedures at our institution, were stratified into three categories of surgical complexity (low, intermediate, and high). There were 73 patients, including 39 women (53.4%) and 34 men (46.6%). The median age was 75 years (range 70-88 years). There were 7, 24, and 42 patients included, respectively, in the low, intermediate, and high surgical complexity categories. Approximately 50% of patients underwent hepatic and pancreatic resections. There was no statistically significant difference between the three groups in terms of morbidity, mortality, readmission or transfusion. Mean overall operative time was 254 ± 133 min (range 15-560 min). Perioperative mortality and morbidity was 1.4% and 15.1%, respectively. Transfusion rate was 9.6%, and median length of stay was 6 days (range 0-30 days). Robotic surgery can be performed safely in the elderly population with low mortality, acceptable morbidity, and short hospital stay. Age should not be considered as a contraindication to robotic surgery even for advanced procedures.

  11. Safety of direct endoscopic necrosectomy in patients with gastric varices

    PubMed Central

    Storm, Andrew C; Thompson, Christopher C

    2016-01-01

    AIM: To determine the feasibility and safety of transgastric direct endoscopic necrosectomy (DEN) in patients with walled-off necrosis (WON) and gastric varices. METHODS: A single center retrospective study of consecutive DEN for WON was performed from 2012 to 2015. All DEN cases with gastric fundal varices noted on endoscopy, computed tomography (CT) or magnetic resonance imaging (MRI) during the admission for DEN were collected for analysis. In all cases, external urethral sphincter (EUS) with doppler was used to exclude the presence of intervening gastric varices or other vascular structures prior to 19 gauge fine-needle aspiration (FNA) needle access into the cavity. The tract was serially dilated to 20 mm and was entered with an endoscope for DEN. Pigtail stents were placed to facilitate drainage of the cavity. Procedure details were recorded. Comprehensive chart review was performed to evaluate for complications and WON recurrence. RESULTS: Fifteen patients who underwent DEN for WON had gastric varices at the time of their procedure. All patients had an INR < 1.5 and platelets > 50. Of these patients, 11 had splenic vein thrombosis and 2 had portal vein thrombosis. Two patients had isolated gastric varices, type 1 and the remaining 13 had > 5 mm gastric submucosal varices on imaging by CT, MRI or EUS. No procedures were terminated without completing the DEN for any reason. One patient had self-limited intraprocedural bleeding related to balloon dilation of the tract. Two patients experienced delayed bleeding at 2 and 5 d post-op respectively. One required no therapy or intervention and the other received 1 unit transfusion and had an EGD which revealed no active bleeding. Resolution rate of WON was 100% (after up to 2 additional DEN in one patient) and no patients required interventional radiology or surgical interventions. CONCLUSION: In patients with WON and gastric varices, DEN using EUS and doppler guidance may be performed safely. Successful resolution

  12. Relationship of hospital organizational culture to patient safety climate in the Veterans Health Administration.

    PubMed

    Hartmann, Christine W; Meterko, Mark; Rosen, Amy K; Shibei Zhao; Shokeen, Priti; Singer, Sara; Gaba, David M

    2009-06-01

    Improving safety climate could enhance patient safety, yet little evidence exists regarding the relationship between hospital characteristics and safety climate. This study assessed the relationship between hospitals' organizational culture and safety climate in Veterans Health Administration (VA) hospitals nationally. Data were collected from a sample of employees in a stratified random sample of 30 VA hospitals over a 6-month period (response rate = 50%; n = 4,625). The Patient Safety Climate in Healthcare Organizations (PSCHO) and the Zammuto and Krakower surveys were used to measure safety climate and organizational culture, respectively. Higher levels of safety climate were significantly associated with higher levels of group and entrepreneurial cultures, while lower levels of safety climate were associated with higher levels of hierarchical culture. Hospitals could use these results to design specific interventions aimed at improving safety climate.

  13. Evaluation of patient safety culture among Malaysian retail pharmacists: results of a self-reported survey

    PubMed Central

    Sivanandy, Palanisamy; Maharajan, Mari Kannan; Rajiah, Kingston; Wei, Tan Tyng; Loon, Tan Wee; Yee, Lim Chong

    2016-01-01

    Background Patient safety is a major public health issue, and the knowledge, skills, and experience of health professionals are very much essential for improving patient safety. Patient safety and medication error are very much associated. Pharmacists play a significant role in patient safety. The function of pharmacists in the medication use process is very different from medical and nursing colleagues. Medication dispensing accuracy is a vital element to ensure the safety and quality of medication use. Objective To evaluate the attitude and perception of the pharmacist toward patient safety in retail pharmacies setup in Malaysia. Methods A Pharmacy Survey on Patient Safety Culture questionnaire was used to assess patient safety culture, developed by the Agency for Healthcare Research and Quality, and the convenience sampling method was adopted. Results The overall positive response rate ranged from 31.20% to 87.43%, and the average positive response rate was found to be 67%. Among all the eleven domains pertaining to patient safety culture, the scores of “staff training and skills” were less. Communication openness, and patient counseling are common, but not practiced regularly in the Malaysian retail pharmacy setup compared with those in USA. The overall perception of patient safety of an acceptable level in the current retail pharmacy setup. Conclusion The study revealed that staff training, skills, communication in patient counseling, and communication across shifts and about mistakes are less in current retail pharmacy setup. The overall perception of patient safety should be improved by educating the pharmacists about the significance and essential of patient safety. PMID:27524887

  14. 76 FR 67456 - Common Formats for Patient Safety Data Collection and Event Reporting

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-01

    ... safety events that reached the patient, whether or not there was harm, ] Near misses or close calls... events. When used as designed, the Common Formats allow collection of information on all harms to patients: ``All-cause harm.'' The VTE format includes a description of the patient safety events to...

  15. Exploring Canadians' and Europeans' Health Care Professionals' Perception of Biological Risks, Patient Safety, and Professional's Safety Practices.

    PubMed

    Bernard, Laurence; Bernard, Agnès; Biron, Alain; Lavoie-Tremblay, Mélanie

    2017-04-03

    Patient safety has become a worldwide concern in relation to infectious diseases (Ebola/severe acute respiratory syndrome/flu). During the pandemic, different sanitary responses were documented between Europe and North America in terms of vaccination and compliance with infection prevention and control measures. The purpose of this study was to explore the health care professional's perceptions of biological risks, patient safety, and their practices in European and Canadian health care facilities. A qualitative-descriptive design was used to explore the perceptions of biological risks and patient safety practices among health care professionals in 3 different facilities. Interviews (n = 39) were conducted with health care professionals in Canada and Europe. The thematic analysis pinpointed 3 main themes: risk and infectious disease, patient safety, and occupational health and safety. These themes fit within safety cultures described by participants: individual culture, blame culture, and collaborative culture. The preventive terminology used in the European health care facility focuses on hospital hygiene from the perspective of environmental risk (individual culture). In Canadian health care facilities, the focus was on risk management for infection prevention either from a punitive perspective (blame culture) or from a collaborative perspective (collaborative culture). This intercultural dialogue described the contextual realities on different continents regarding the perceptions of health care professionals about risks and infections.

  16. Setting priorities for reducing risk and advancing patient safety.

    PubMed

    Gaffey, Ann D

    2016-04-01

    We set priorities every day in both our personal and professional lives. Some decisions are easy, while others require much more thought, participation, and resources. The difficult or less appealing priorities may not be popular, may receive push-back, and may be resource intensive. Whether personal or professional, the urgency that accompanies true priorities becomes a driving force. It is that urgency to ensure our patients' safety that brings many of us to work each day. This is not easy work. It requires us to be knowledgeable about the enterprise we are working in and to have the professional skills and competence to facilitate setting the priorities that allow our organizations to minimize risk and maximize value.

  17. Safety of pharmacotherapy of osteoporosis in cardiology patients.

    PubMed

    Zapolski, Tomasz; Wysokiński, Andrzej

    2010-01-01

    The commonest medical conditions following menopause are osteoporosis and atherosclerotic disease. This review considers the safety of pharmacotherapy of osteoporosis in cardiology patients. Drugs used for osteoporosis treatment may have adverse effects on the cardiovascular system. This article has detailed analysed of current drug classes, such as the bisphosphonates and strontium ranelate, as well as reviewed of the controversy surrounding hormone replacement therapy (HRT) and the selective estrogen receptor modulators (SERMs). Additionally, we discuss the adverse effects on the heart of calcium and drugs influencing calcium metabolism such as vitamin D, parathormone and calcitonin. We look at the interference between osteoporosis treatment and the drugs used for atherosclerosis. Moreover, the side effects on bones of cardiology drugs are analysed. Lastly, the possible advantages of selected drugs used for cardiovascular diseases in terms of osteoporosis prevention are evaluated.

  18. [Placement of central venous catheters and patient safety].

    PubMed

    de Jonge, E

    2007-01-27

    Placement of a central venous catheter is one of the most common invasive procedures and is associated with septic and mechanical complications, such as bleeding and pneumothorax. Up to 30% of attempts to cannulate the central vein fail. Correct positioning of the patient can help to maximise the success rate. For placement of catheters in the subclavian vein, patients should be in the Trendelenburg position without the use of a shoulder roll to retract the shoulders. Traditionally, central venous catheters are placed using a 'blind' technique that relies on external anatomical reference marks to localise the vein. However, unnoticed anatomical variations or central venous thrombosis may contribute to cannulation failure with this technique. The use of ultrasound has been shown to increase the success rate and avoid mechanical complications when placing a catheter in the internal jugular vein. It may also increase the success rate in subclavian vein catheterisation. To increase patient safety, the use of ultrasound when placing a central venous catheter should be embraced and become the standard of care.

  19. Patient safety in elderly hip fracture patients: design of a randomised controlled trial

    PubMed Central

    2011-01-01

    Background The clinical environment in which health care providers have to work everyday is highly complex; this increases the risk for the occurrence of unintended events. The aim of this randomised controlled trial is to improve patient safety for a vulnerable group of patients that have to go through a complex care chain, namely elderly hip fracture patients. Methods/design A randomised controlled trial that consists of three interventions; these will be implemented in three surgical wards in Dutch hospitals. One surgical ward in another hospital will be the control group. The first intervention is aimed at improving communication between care providers using the SBAR communication tool. The second intervention is directed at stimulating the role of the patient within the care process with a patient safety card. The third intervention consists of a leaflet for patients with information on the most common complications for the period after discharge. The primary outcome measures in this study are the incidence of complications and adverse events, mortality rate within six months after discharge and functional mobility six months after discharge. Secondary outcome measures are length of hospital stay, quality and completeness of information transfer and patient satisfaction with the instruments. Discussion The results will give insight into the nature and scale of complications and adverse events that occur in elderly hip fracture patients. Also, the implementation of three interventions aimed at improving the communication and information transfer provides valuable possibilities for improving patient safety in this increasing patient group. This study combines the use of three interventions, which is an innovative aspect of the study. Trial registration The Netherlands National Trial Register NTR1562 PMID:21418630

  20. 78 FR 17212 - Patient Safety Organizations: Voluntary Relinquishment From Universal Safety Solution PSO

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-20

    ... Relinquishment From Universal Safety Solution PSO AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS.... AHRQ has accepted a notification of voluntary relinquishment from Universal Safety Solution PSO of its... the list of federally approved PSOs. AHRQ has accepted a notification from Universal Safety...

  1. Electronic distractions of the respiratory therapist and their impact on patient safety.

    PubMed

    Papadakos, Peter J

    2014-08-01

    Over the last decade, data from the lay press, government agencies, and the business world have identified ever-growing problems with electronic distraction and changes in human relationships in this electronically interconnected planet. As health professionals, we are well aware of the epidemic growth of injuries and deaths related to texting and driving. It should not surprise us that this distracted behavior has affected all levels of health-care providers and has impacted patient care. This advent of “distracted doctoring” was first coined by the Pulitzer Prize-winning correspondent Matt Richtel in a landmark article in the New York Times, “As doctors use more devices, potential for distraction grows.” This article was a flashpoint for professional organizations to reflect on this change in behavior and how it will impact patient safety and how we relate to patients. The explosion in technology (both personnel and hospital-based), coupled with a rapid social shift, creates an environment that constantly tempts health-care workers to surf the internet, check social media outlets, or respond to e-mails. Studies and commentaries in the medical literature only support how this is a growing problem in patient safety and may both increase medical errors and affects costs and the way we relate to patients and fellow staff. The Emergency Care Research Institute (ECRI) released its annual list of technology hazards for 2013, and three ring true for United States caregivers: distractions from smartphones and mobile devices, alarm hazards, and patient/data mismatches in electronic medical records and other health IT systems, all being in the top 10. How do we begin to address these new technological threats to our patients? First and foremost, we accept that this problem exists. We begin by educating our students and staff that this electronic explosion affects our behavior through addiction and the environment within our hospital through the use of electronic

  2. Beyond engagement in working with children in eight Nairobi slums to address safety, security, and housing: Digital tools for policy and community dialogue.

    PubMed

    Mitchell, Claudia; Chege, Fatuma; Maina, Lucy; Rothman, Margot

    2016-01-01

    This article studies the ways in which researchers working in the area of health and social research and using participatory visual methods might extend the reach of participant-generated creations such as photos and drawings to engage community leaders and policy-makers. Framed as going 'beyond engagement', the article explores the idea of the production of researcher-led digital dialogue tools, focusing on one example, based on a series of visual arts-based workshops with children from eight slums in Nairobi addressing issues of safety, security, and well-being in relation to housing. The authors conclude that there is a need for researchers to embark upon the use of visual tools to expand the life and use of visual productions, and in particular to ensure meaningful participation of communities in social change.

  3. [Role of reporting and learning systems in the improvement of patient safety].

    PubMed

    Lám, Judit; Sümegi, Viktória; Surján, Cecília; Kullmann, Lajos; Belicza, Éva

    2016-06-26

    The principles and requirements of a patient safety related reporting and learning system were defined by the World Health Organization Draft Guidelines for Adverse Event Reporting and Learning Systems published in 2005. Since then more and more Hungarian health care organizations aim to improve their patient safety culture. In order to support this goal the NEVES reporting and learning system and the series of Patient Safety Forums for training and consultation were launched in 2006 and significantly renewed recently. Current operative modifications to the Health Law emphasize patient safety, making the introduction of these programs once again necessary.

  4. Physicians' and nurses' perceptions of patient safety risks in the emergency department.

    PubMed

    Källberg, Ann-Sofie; Ehrenberg, Anna; Florin, Jan; Östergren, Jan; Göransson, Katarina E

    2017-02-28

    The emergency department has been described as a high-risk area for errors. It is also known that working conditions such as a high workload and shortage off staff in the healthcare field are common factors that negatively affect patient safety. A limited amount of research has been conducted with regard to patient safety in Swedish emergency departments. Additionally, there is a lack of knowledge about clinicians' perceptions of patient safety risks. Therefore, the purpose of this study was to describe emergency department clinicians' experiences with regard to patient safety risks.

  5. Measuring patient safety in a UK dental hospital: development of a dental clinical effectiveness dashboard.

    PubMed

    Pemberton, M N; Ashley, M P; Shaw, A; Dickson, S; Saksena, A

    2014-10-01

    Patient safety is an important marker of quality for any healthcare organisation. In 2008, the British Government white paper entitled High quality care for all, resulting from a review led by Lord Darzi, identified patient safety as a key component of quality and discussed how it might be measured, analysed and acted upon. National and local clinically curated metrics were suggested, which could be displayed via a 'clinical dashboard'. This paper explains the development of a clinical effectiveness dashboard focused on patient safety in an English dental hospital and how it has helped us identify relevant patient safety issues in secondary dental care.

  6. Addressing Barriers to Shared Decision Making Among Latino LGBTQ Patients and Healthcare Providers in Clinical Settings.

    PubMed

    Baig, Arshiya A; Lopez, Fanny Y; DeMeester, Rachel H; Jia, Justin L; Peek, Monica E; Vela, Monica B

    2016-10-01

    Effective shared decision making (SDM) between patients and healthcare providers has been positively associated with health outcomes. However, little is known about the SDM process between Latino patients who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ), and their healthcare providers. Our review of the literature identified unique aspects of Latino LGBTQ persons' culture, health beliefs, and experiences that may affect their ability to engage in SDM with their healthcare providers. Further research needs to examine Latino LGBTQ patient-provider experiences with SDM and develop tools that can better facilitate SDM in this patient population.

  7. Implementing a national strategy for patient safety: lessons from the National Health Service in England.

    PubMed

    Lewis, R Q; Fletcher, M

    2005-04-01

    Improving patient safety has become a core issue for many modern healthcare systems. However, knowledge of the best ways for government initiated efforts to improve patient safety is still evolving, although there is considerable commonality in the challenges faced by countries. Actions to improve patient safety must operate at multiple levels of the healthcare system simultaneously. Using the example of the NHS in England, this article highlights the importance of a strategic analysis of the policy process and the prevailing policy context in the design of the national patient safety strategy. The paper identifies a range of policy "levers" (forces for change) that can be used to support the implementation of the national safety initiative and, in particular, discusses the strengths and limitations of the "business case" approach that has attracted recent interest. The paper offers insights into the implementation of national patient safety goals that should provide learning for other countries.

  8. From Here to There: Lessons from an Integrative Patient Safety Project in Rural Health Care Settings

    DTIC Science & Technology

    2005-05-01

    Pilot Safety Culture Assessment, developed by the Department of Veterans Affairs; an Error Tool Survey and a Patient Safety Staff Survey that were...Safety Culture Assessment, completed by all the team members, assessed attitudes and beliefs relative to the recognition, reporting, and disclosing...College to revisit, reconsider, and revise. Admittedly this methodology is time- consuming for the researchers and the research participants

  9. Don't blame patients, engage them: transforming health systems to address health literacy.

    PubMed

    Frosch, Dominick L; Elwyn, Glyn

    2014-01-01

    The passage of the Patient Protection and Affordable Care Act is affirming a new era for health care delivery in the United States, with an increased focus on patient engagement. The field of health literacy has important contributions to make, and there are opportunities to achieve much more synergy between these seemingly different perspectives. Systems need to be designed in a user-centered way that is responsive to patients at all levels of health literacy. Similarly, strategies are needed to ensure that patients are supported to become engaged, at the level they desire, instead of the status quo, in which patients are rarely actively empowered and encouraged to engage in health care decisions, where preferences are rarely elicited, and where there is a lack of interest in how their life circumstances shape their priorities.

  10. [Safety profile of rilpivirine: general and neuropsychiatric tolerability, safety in patients with hepatitis B or C viruses, and lipid profile].

    PubMed

    López Cortés, Luis F; Martínez, Esteban; von Wichmann, Miguel Ángel

    2013-06-01

    Currently available data on the safety and tolerability of rilpivirine come from the product information document, a phase IIb, dose-finding clinical trial (TMC278-C204), the phase III ECHO and THRIVE clinical trials, and the preliminary data from the STaR and SPIRIT clinical trials, with a total of 1,728 patients. The comparator has usually been efavirenz. All studies have found a lower incidence and severity of neuropsychiatric adverse effects, a better lipid profile, and a lower number of patients with subclinical transaminase elevation in patients treated with rilpivirine. However, because of the relatively low number of patients coinfected with hepatitis B or C virus, definitive conclusions cannot be drawn. Similarly, experience in patients with mild or moderate liver failure is limited and there are no safety data in patients with advanced liver failure.

  11. Patient safety culture in two Finnish state-run forensic psychiatric hospitals.

    PubMed

    Kuosmanen, Anssi; Tiihonen, Jari; Repo-Tiihonen, Eila; Eronen, Markku; Turunen, Hannele

    2013-01-01

    Safety culture refers to the way patient safety is regarded and implemented within an organization and the structures and procedures in place to support this. The aim of this study was to evaluate patient safety culture, identify areas for improvement, and establish a baseline for improving state hospitals in Finland. Cross-sectional design data were collected from two state-run forensic hospitals in Finland using an anonymous, Web-based survey targeted to hospital staff based on the Hospital Survey on Patient Safety Culture questionnaire. The response rate was 43% (n = 283). The overall patient safety level was rated as excellent or very good by 58% of respondents. The highest positive grade was for "teamwork within units" (72%). The lowest rating was for "nonpunitive response to errors" (26% positive). Good opportunities for supplementary education had a statistically significant (p ≤ 0.05) effect on 9 of 12 Hospital Survey on Patient Safety Culture dimensions. Statistically significant (p ≤ 0.05) differences in patient safety culture were also found in the staff's educational background, manager status, and between the two hospitals. These findings suggest there are a number of patient safety problems related to cultural dimensions. Supplementary education was shown to be a highly significant factor in transforming patient safety culture and should therefore be taken into account alongside sufficient resources.

  12. Quality indicators for patient safety in primary care. A review and Delphi-survey by the LINNEAUS collaboration on patient safety in primary care

    PubMed Central

    Frigola-Capell, Eva; Pareja-Rossell, Clara; Gens-Barber, Montse; Oliva-Oliva, Glòria; Alava-Cano, Fernando; Wensing, Michel; Davins-Miralles, Josep

    2015-01-01

    ABSTRACT Background: Quality indicators are measured aspects of healthcare, reflecting the performance of a healthcare provider or healthcare system. They have a crucial role in programmes to assess and improve healthcare. Many performance measures for primary care have been developed. Only the Catalan model for patient safety in primary care identifies key domains of patient safety in primary care. Objective: To present an international framework for patient safety indicators in primary care. Methods: Literature review and online Delphi-survey, starting from the Catalan model. Results: A set of 30 topics is presented, identified by an international panel and organized according to the Catalan model for patient safety in primary care. Most topic areas referred to specific clinical processes; additional topics were leadership, people management, partnership and resources. Conclusion: The framework can be used to organize indicator development and guide further work in the field. PMID:26339833

  13. Fragmentation of Patient Safety Research: A Critical Reflection of Current Human Factors Approaches to Patient Handover

    PubMed Central

    Manser, Tanja

    2013-01-01

    The integration of human factors science in research and interventions aimed at increased patient safety has led to considerable improvements. However, some challenges to patient safety persist and may require human factors experts to critically reflect upon their predominant approaches to research and improvement. This paper is a call to start a discussion of these issues in the area of patient handover. Briefly reviewing recent handover research shows that while these studies have provided valuable insights into the communication practices for a range of handover situations, the predominant research strategy of studying isolated handover episodes replicates the very problem of fragmentation of care that the studies aim to overcome. Thus, there seems to be a need for a patient-centred approach to handover research that aims to investigate the interdependencies of handover episodes during a series of transitions occurring along the care path. Such an approach may contribute to novel insights and help to increase the effectiveness and sustainability of interventions to improve handover. Significance for public health While much of public health research has a preventive focus, health services research is generally concerned with the ways in which care is provided to those requiring treatment. This paper calls for a patient-centred approach to research on patient handover; a significant contributor to adverse events in healthcare. It is argued that this approach has the potential to improve our understanding of handover processes along the continuum of care. Thus, it can provide a scientific foundation for effective improvements in handover that are likely to reduce patient harm and help to maintain patient safety. PMID:25170504

  14. Promoting patient safety and preventing medical error in emergency departments.

    PubMed

    Schenkel, S

    2000-11-01

    An estimated 108,000 people die each year from potentially preventable iatrogenic injury. One in 50 hospitalized patients experiences a preventable adverse event. Up to 3% of these injuries and events take place in emergency departments. With long and detailed training, morbidity and mortality conferences, and an emphasis on practitioner responsibility, medicine has traditionally faced the challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners. Yet no matter how well trained and how careful health care providers are, individuals will make mistakes because they are human. In general medicine, the study of adverse drug events has led the way to new methods of error detection and error prevention. A combination of chart reviews, incident logs, observation, and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order review. In emergency medicine (EM), error detection has focused on subjects of high liability: missed myocardial infarctions, missed appendicitis, and misreading of radiographs. Some system-level efforts in error prevention have focused on teamwork, on strengthening communication between pharmacists and emergency physicians, on automating drug dosing and distribution, and on rationalizing shifts. This article reviews the definitions, detection, and presentation of error in medicine and EM. Based on review of the current literature, recommendations are offered to enhance the likelihood of reduction of error in EM practice.

  15. Can addressing death anxiety reduce health care workers' burnout and improve patient care?

    PubMed

    Melo, Carol Gouveia; Oliver, David

    2011-01-01

    Death anxiety may interfere with health care workers' (HCWs) relationships with patients and patients' families and increase HCWs' levels of burnout. This study shows the impact of a six-day course for HCWs that provided training in communication, in offering emotional and spiritual support to patients, and in personal introspection on death anxiety. The HCWs were given questionnaires to evaluate their level of burnout, personal well-being, and death anxiety as well as the quality of their relationships with patients before the course and four months after it. There were 150 study participants, all HCWs involved in caring for dying patients (85 in palliative care units and 65 in other settings). There was a control group of 26 HCWs who cared for the dying in settings other than palliative care units. The results show that the course appeared to lead to a significant reduction in levels of burnout and death anxiety; they also indicated an increase in personal well-being and professional fulfillment, and participants perceived an improvement in the quality of their relationships with patients and patients' families.

  16. Addressing the general medical needs of a patient with an altered mental state.

    PubMed

    Boyer, Jenny L; Ginzburg, Harold M; Shah, Parind; Ardoin, Stan

    2008-12-01

    Patients presenting to an Emergency Department with an altered mental state, whether from a psychiatric, medical or surgical condition or a combination of psychiatric and medical or surgical conditions, require more than the usual amount of diagnostic acumen. General medical conditions often appear in the guise of dysfunctional emotions and/or behaviors. Acute and chronic psychosis may mask underlying acute and chronic medical and surgical conditions. As the case of Esmin Green of Brooklyn, New York, illustrates, the failure to identify underlying medical and surgical conditions in delirious, demented, or psychotic patients can prove fatal to the patient and economically costly to the medical center and its employees.

  17. Addressing Barriers to Shared Decision Making Among Latino LGBTQ Patients and Healthcare Providers in Clinical Settings

    PubMed Central

    Lopez, Fanny Y.; DeMeester, Rachel H.; Jia, Justin L.; Peek, Monica E.; Vela, Monica B.

    2016-01-01

    Abstract Effective shared decision making (SDM) between patients and healthcare providers has been positively associated with health outcomes. However, little is known about the SDM process between Latino patients who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ), and their healthcare providers. Our review of the literature identified unique aspects of Latino LGBTQ persons’ culture, health beliefs, and experiences that may affect their ability to engage in SDM with their healthcare providers. Further research needs to examine Latino LGBTQ patient–provider experiences with SDM and develop tools that can better facilitate SDM in this patient population. PMID:27617356

  18. Affect is central to patient safety: the horror stories of young anaesthetists.

    PubMed

    Iedema, Rick; Jorm, Christine; Lum, Martin

    2009-12-01

    This paper analyses talk produced by twenty-four newly qualified anaesthetists. Data were collected from round table discussions at the Young Fellows Conference of the Australia and New Zealand College of Anaesthetists 2006. The talk consisted to an important extent of narratives about experiences of horror. The paper isolates three themes: the normalization of horror, the functionalisation of horror for pedagogic purposes, and the problematization of horror. The last theme provides a springboard into our argument that confronting the affect invested in coping with medical-clinical failure is central to enabling young doctors, and clinicians generally, to address and resolve such adverse events. We conclude that the negotiation of affect through shared or 'dialogic' narrative is central to enabling doctors to deal with adverse events on a personal level, and to enabling them at a collective level to become attentive to threats to patients' safety.

  19. Religiosity/spirituality of German doctors in private practice and likelihood of addressing R/S issues with patients.

    PubMed

    Voltmer, Edgar; Bussing, Arndt; Koenig, Harold G; Al Zaben, Faten

    2014-12-01

    This study examined the self-assessed religiosity and spirituality (R/S) of a representative sample of German physicians in private practice (n = 414) and how this related to their addressing R/S issues with patients. The majority of physicians (49.3 %)reported a Protestant denomination, with the remainder indicating mainly either Catholic(12.5 %) or none (31.9 %). A significant proportion perceived themselves as either religious(42.8 %) or spiritual (29.0 %). Women were more likely to rate themselves R/S than did men. Women (compared to men) were also somewhat more likely to attend religious services (7.4 vs. 2.1 % at least once a week) and participate in private religious activities(14.9 vs. 13.7 % at least daily), although these differences were not statistically significant.The majority of physicians (67.2 %) never/seldom addressed R/S issues with a typical patient. Physicians with higher self-perceived R/S and more frequent public and private religious activity were much more likely to address R/S issues with patients. Implications for patient care and future research are discussed.

  20. Older, vulnerable patient view: a pilot and feasibility study of the patient measure of safety (PMOS) with patients in Australia

    PubMed Central

    Taylor, Natalie; Hogden, Emily; Clay-Williams, Robyn; Li, Zhicheng; Lawton, Rebecca; Braithwaite, Jeffrey

    2016-01-01

    Objectives The UK-developed patient measure of safety (PMOS) is a validated tool which captures patient perceptions of safety in hospitals. We aimed (1) to investigate the extent to which the PMOS is appropriate for use with stroke, acute myocardial infarction (AMI) and hip fracture patients in Australian hospitals and (2) to pilot the PMOS for use in a large-scale, national study ‘Deepening our Understanding of Quality in Australia’ (DUQuA). Participants Stroke, AMI and hip fracture patients (n=34) receiving care in 3 wards in 1 large hospital. Methods 2 phases were conducted. First, a ‘think aloud’ study was used to determine the validity of PMOS with this population in an international setting, and to make amendments based on patient feedback. The second phase tested the revised measure to establish the internal consistency reliability of the revised subscales, and piloted the recruitment and administration processes to ensure feasibility of the PMOS for use in DUQuA. Results Of the 43 questions in the PMOS, 13 (30%) were amended based on issues patients highlighted for improvement in phase 1. In phase 2, a total of 34 patients were approached and 29 included, with a mean age of 71.3 years (SD=16.39). Internal consistency reliability was established using interitem correlation and Cronbach's α for all but 1 subscale. The most and least favourably rated aspects of safety differed between the 3 wards. A study log was categorised into 10 key feasibility factors, including liaising with wards to understand operational procedures and identify patterns of patient discharge. Conclusions Capturing patient perceptions of care is crucial in improving patient safety. The revised PMOS is appropriate for use with vulnerable older adult groups. The findings from this study have informed key decisions made for the deployment of this measure as part of the DUQuA study. PMID:27279478

  1. Assessment of patient safety culture among healthcare providers at a teaching hospital in Cairo, Egypt.

    PubMed

    Aboul-Fotouh, A M; Ismail, N A; Ez Elarab, H S; Wassif, G O

    2012-04-01

    A previous study in Cairo, Egypt highlighted the need to improve the patient safety culture among health-care providers at Ain Shams University hospitals. This descriptive cross-sectional study assessed healthcare providers' perceptions of patient safety culture within the organization and determined factors that played a role in patient safety culture. A representative sample of 510 physicians, nurses, pharmacists, technicians and labourers in different departments answered an Arabic version of the Agency of Healthcare Research and Quality hospital survey for patient safety culture. The highest mean composite positive score among the 12 dimensions was for the organizational learning for continuous improvement (78.2%), followed by teamwork (58.1%). The lowest mean score was for the dimension of non-punitive response to error (19.5%). Patient safety culture still has many areas for improvement that need continuous evaluation and monitoring to attain a safe environment both for patients and health-care providers.

  2. Pharmaceutical digital marketing and governance: illicit actors and challenges to global patient safety and public health

    PubMed Central

    2013-01-01

    Background Digital forms of direct-to-consumer pharmaceutical marketing (eDTCA) have globalized in an era of free and open information exchange. Yet, the unregulated expansion of eDTCA has resulted in unaddressed global public health threats. Specifically, illicit online pharmacies are engaged in the sale of purportedly safe, legitimate product that may in fact be counterfeit or substandard. These cybercriminal actors exploit available eDTCA mediums over the Internet to market their suspect products globally. Despite these risks, a detailed assessment of the public health, patient safety, and cybersecurity threats and governance mechanisms to address them has not been conducted. Discussion Illicit online pharmacies represent a significant global public health and patient safety risk. Existing governance mechanisms are insufficient and include lack of adequate adoption in national regulation, ineffective voluntary governance mechanisms, and uneven global law enforcement efforts that have allowed proliferation of these cybercriminals on the web. In order to effectively address this multistakeholder threat, inclusive global governance strategies that engage the information technology, law enforcement and public health sectors should be established. Summary Effective global “eHealth Governance” focused on cybercrime is needed in order to effectively combat illicit online pharmacies. This includes building upon existing Internet governance structures and coordinating partnership between the UN Office of Drugs and Crime that leads the global fight against transnational organized crime and the Internet Governance Forum that is shaping the future of Internet governance. Through a UNODC-IGF governance mechanism, investigation, detection and coordination of activities against illicit online pharmacies and their misuse of eDTCA can commence. PMID:24131576

  3. An analysis of the utilization of e-mail by physicians and patients: defining benefits, addressing concerns and forecasting implications on the doctor-patient relationship.

    PubMed

    Lang, Kirk T; Kiel, Joan M

    2008-01-01

    Though e-mail is ubiquitous in everyday life, it has not been the preferred mode of communication between physicians and patients. Several factors, including privacy and security, reimbursement and legal concerns, have been seen as barriers toward increased utilization. This article examines effect of e-mail on the doctor-patient relationship. It also addresses concerns expressed by providers and patients, and explores technology- and policy-based solutions to many of these issues.

  4. Alternative therapies to address the unmet medical needs of patients with phenylketonuria.

    PubMed

    Blau, Nenad; Longo, Nicola

    2015-04-01

    Standard therapy for phenylketonuria (PKU), the most common inherited disorder in amino acid metabolism, is an onerous phenylalanine-restricted diet. Adherence to this stringent diet regimen decreases as patients get older, and this lack of adherence is directly associated with cognitive and executive dysfunction and psychiatric issues. These factors emphasize the need for alternative pharmacological therapies to help treat patients with PKU. Sapropterin dihydrochloride is a synthetic form of tetrahydrobiopterin, the cofactor of phenylalanine hydroxylase that in pharmacological doses can stabilize and increase residual enzyme activity in some patients with PKU. About one-third of all patients with PKU respond to oral sapropterin. Phenylalanine ammonia lyase (PAL) is a prokaryotic enzyme that converts phenylalanine to ammonia and trans-cinnamic acid. Phase I and II trials have shown that injectable recombinant Anabaena variabilis PAL produced in Escherichia coli conjugated with PEG can reduce phenylalanine levels in subjects with PKU. The most frequently reported adverse events were injection-site reactions, dizziness and immune reactions. Additionally, oral administration of PAL and delivery of enzyme substitution therapies by encapsulation in erythrocytes are being investigated. Novel therapies for patients with PKU appear to be options to reduce phenylalanine levels, and may reduce the deleterious effects of this disorder.

  5. Trustworthy patient decision aids: a qualitative analysis addressing the risk of competing interests

    PubMed Central

    Elwyn, Glyn; Dannenberg, Michelle; Blaine, Arianna; Poddar, Urbashi; Durand, Marie-Anne

    2016-01-01

    Objective Our aim in this study was to examine the competing interest policies and procedures of organisations who develop and maintain patient decision aids. Design Descriptive and thematic analysis of data collected from a cross-sectional survey of patient decision aid developer's competing interest policies and disclosure forms. Results We contacted 25 organisations likely to meet the inclusion criteria. 12 eligible organisations provided data. 11 organisations did not reply and 2 declined to participate. Most patient decision aid developers recognise the need to consider the issue of competing interests. Assessment processes vary widely and, for the most part, are insufficiently robust to minimise the risk of competing interests. Only half of the 12 organisations had competing interest policies. Some considered disclosure to be sufficient, while others imposed differing levels of exclusion. Conclusions Patient decision aid developers do not have a consistent approach to managing competing interests. Some have developed policies and procedures, while others pay no attention to the issue. As is the case for clinical practice guidelines, increasing attention will need to be given to how the competing interests of contributors of evidence-based publications may influence materials, especially if they are designed for patient use. PMID:27612542

  6. Utility and safety of tolvaptan in cirrhotic patients with hyponatremia: A prospective cohort study.

    PubMed

    Jia, Ji-Dong; Xie, Wen; Ding, Hui-Guo; Mao, Hua; Guo, Hui; Li, Yonggang; Wang, Xiaojin; Wang, Jie-Fei; Lu, Wei; Li, Cheng-Zhong; Mao, Yimin; Wang, Gui-Qiang; Gao, Yue-Qiu; Wang, Bangmao; Zhang, Qin; Ge, Yan; Wong, Vincent Wai-Sun

    2017-01-01

    Introduction and aim. Hyponatremia is common in patients with decompensated cirrhosis and is associated with increased mortality. Tolvaptan, a vasopressor V2 receptor antagonist, can increase free water excretion, but its efficacy and safety in cirrhotic patients remain unclear.

  7. Studying large-scale programmes to improve patient safety in whole care systems: challenges for research.

    PubMed

    Benn, Jonathan; Burnett, Susan; Parand, Anam; Pinto, Anna; Iskander, Sandra; Vincent, Charles

    2009-12-01

    Large-scale national and multi-institutional patient safety improvement programmes are being developed in the health care systems of several countries to address problems in the reliability of care delivered to patients. Drawing upon popular collaborative improvement models, these campaigns are ambitious in their aims to improve patient safety in macro-level systems such as whole health care organisations. This article considers the methodological issues involved in conducting research and evaluation of these programmes. Several specific research challenges are outlined, which result from the complexity of longitudinal, multi-level intervention programmes and the variable, highly sociotechnical care systems, with which they interact. Organisational-level improvement programmes are often underspecified due to local variations in context and organisational readiness for improvement work. The result is variable implementation patterns and local adaptations. Programme effects span levels and other boundaries within a system, vary dynamically or are cumulative over time and are problematic to understand in terms of cause and effect, where concurrent external influences exist and the impact upon study endpoints may be mediated by a range of organisational and social factors. We outline the methodological approach to research in the United Kingdom Safer Patients Initiative, to exemplify how some of the challenges for research in this area can be met through a multi-method, longitudinal research design. Specifically, effective research designs must be sensitive to complex variation, through employing multiple qualitative and quantitative measures, collect data over time to understand change and utilise descriptive techniques to capture specific interactions between programme and context for implementation. When considering the long-term, sustained impact of an improvement programme, researchers must consider how to define and measure the capability for continuous safe and

  8. Survivorship Care Plan Information Needs: Perspectives of Safety-Net Breast Cancer Patients

    PubMed Central

    Napoles, Tessa M.; Banks, Priscilla J.; Orenstein, Fern S.; Luce, Judith A.; Joseph, Galen

    2016-01-01

    Purpose Despite the Institute of Medicine’s (IOM) 2005 recommendation, few care organizations have instituted standard survivorship care plans (SCPs). Low health literacy and low English proficiency are important factors to consider in SCP development. Our study aimed to identify information needs and survivorship care plan preferences of low literacy, multi-lingual patients to support the transition from oncology to primary care and ongoing learning in survivorship. Methods We conducted focus groups in five languages with African American, Latina, Russian, Filipina, White, and Chinese medically underserved breast cancer patients. Topics explored included the transition to primary care, access to information, knowledge of treatment history, and perspectives on SCPs. Results Analysis of focus group data identified three themes: 1) the need for information and education on the transition between “active treatment” and “survivorship”; 2) information needed (and often not obtained) from providers; and 3) perspectives on SCP content and delivery. Conclusions Our data point to the need to develop a process as well as written information for medically underserved breast cancer patients. An SCP document will not replace direct communication with providers about treatment, symptom management and transition, a communication that is missing in participating safety-net patients’ experiences of cancer care. Women turned to peer support and community-based organizations in the absence of information from providers. Implications for Cancer Survivors “Clear and effective” communication of survivorship care for safety-net patients requires dedicated staff trained to address wide-ranging information needs and uncertainties. PMID:27992491

  9. 42 CFR 3.206 - Confidentiality of patient safety work product.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... research. (i) Disclosure of patient safety work product to persons carrying out research, evaluation or... Secretary, for the purpose of conducting research. (ii) If the patient safety work product disclosed... permitted under the HIPAA Privacy Rule. (7) Disclosure to the Food and Drug Administration (FDA)...

  10. 42 CFR 3.206 - Confidentiality of patient safety work product.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... research. (i) Disclosure of patient safety work product to persons carrying out research, evaluation or... Secretary, for the purpose of conducting research. (ii) If the patient safety work product disclosed... permitted under the HIPAA Privacy Rule. (7) Disclosure to the Food and Drug Administration (FDA)...

  11. 42 CFR 3.206 - Confidentiality of patient safety work product.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... research. (i) Disclosure of patient safety work product to persons carrying out research, evaluation or... Secretary, for the purpose of conducting research. (ii) If the patient safety work product disclosed... permitted under the HIPAA Privacy Rule. (7) Disclosure to the Food and Drug Administration (FDA)...

  12. 42 CFR 3.206 - Confidentiality of patient safety work product.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... research. (i) Disclosure of patient safety work product to persons carrying out research, evaluation or... Secretary, for the purpose of conducting research. (ii) If the patient safety work product disclosed... permitted under the HIPAA Privacy Rule. (7) Disclosure to the Food and Drug Administration (FDA)...

  13. 42 CFR 3.206 - Confidentiality of patient safety work product.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... research. (i) Disclosure of patient safety work product to persons carrying out research, evaluation or... Secretary, for the purpose of conducting research. (ii) If the patient safety work product disclosed... permitted under the HIPAA Privacy Rule. (7) Disclosure to the Food and Drug Administration (FDA)...

  14. 78 FR 55257 - Patient Safety and Quality Improvement: Civil Money Penalty Inflation Adjustment

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-10

    ... HUMAN SERVICES Patient Safety and Quality Improvement: Civil Money Penalty Inflation Adjustment AGENCY... an adjustment to the maximum civil money penalty amount for violations of the confidentiality... or reckless violation of the Patient Safety Act and 42 CFR part 3 shall be subject to a civil...

  15. Cultures for improving patient safety through learning: the role of teamwork.

    PubMed

    Firth-Cozens, J

    2001-12-01

    Improvements in patient safety result primarily from organisational and individual learning. This paper discusses the learning that can take place within organisations and the cultural change necessary to encourage it. It focuses on teams and team leaders as potentially powerful forces for bringing about the management of patient safety and better quality of care.

  16. Roadmap to an effective quality improvement and patient safety program implementation in a rural hospital setting.

    PubMed

    Ingabire, Willy; Reine, Petera M; Hedt-Gauthier, Bethany L; Hirschhorn, Lisa R; Kirk, Catherine M; Nahimana, Evrard; Nepomscene Uwiringiyemungu, Jean; Ndayisaba, Aphrodis; Manzi, Anatole

    2015-12-01

    Implementation lessons: (1) implementation of an effective quality improvement and patient safety program in a rural hospital setting requires collaboration between hospital leadership, Ministry of Health and other stakeholders. (2) Building Quality Improvement (QI) capacity to develop engaged QI teams supported by mentoring can improve quality and patient safety.

  17. Patient Safety Curriculum for Anatomic Pathology Trainees: Recommendations Based on Institutional Experience.

    PubMed

    Samulski, Teresa D; Montone, Kathleen; LiVolsi, Virginia; Patel, Ketan; Baloch, Zubair

    2016-03-01

    Because of the unique systems and skills involved in patient care by the pathologist, it is challenging to design and implement relevant training in patient safety for pathology trainees. We propose a patient safety curriculum for anatomic pathology (AP) residents based on our institutional experience. The Hospital of the University of the Pennsylvania employs a self-reporting safety database. The occurrences from July 2013 to June 2015 recorded in this system that involved the division of AP were reviewed and cataloged as preanalytic, analytic, and postanalytic. The distribution of these occurrences was then used to create a framework for curriculum development in AP. We identified areas in which trainees are involved in the identification and prevention of common patient safety errors that occur in our AP department. Using these data-proven target areas, and employing current Accreditation Council for Graduate Medical Education recommendations and patient safety literature, a strategy for delivering relevant patient safety training is proposed. Teaching patient safety to pathology trainees is a challenging, yet necessary, component of AP training programs. By analyzing the patient safety errors that occur in the AP department, relevant and actionable training can be developed. This provides quality professional development and improves overall performance as trainees are integrated into laboratory systems.

  18. 77 FR 65892 - Patient Safety Organizations: Voluntary Relinquishment From PDR Secure, LLC

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-10-31

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary...), Public Law 109-41, 42 U.S.C. 299b-21-b-26, provides for the formation of Patient Safety Organizations... PSOs, which are entities or component organizations whose mission and primary activity is to...

  19. [Implementation of a patient safety strategy in primary care of the Community of Madrid].

    PubMed

    Cañada Dorado, A; Drake Canela, M; Olivera Cañadas, G; Mateos Rodilla, J; Mediavilla Herrera, I; Miquel Gómez, A

    2015-01-01

    This paper describes the implementation of a patient safety strategy in primary care within the new organizational and functional structure that was created in October 2010 to cover the single primary health care area of the Community of Madrid. The results obtained in Patient Safety after the implementation of this new model over the first two years of its development are also presented.

  20. 77 FR 22322 - Common Formats for Patient Safety Data Collection and Event Reporting

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-04-13

    ... Collection and Event Reporting AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice... patient safety events to Patient Safety Organizations (PS0s). The purpose of this notice is to announce... events and quality of care. Information that is assembled and developed by providers for reporting...

  1. 76 FR 12358 - Common Formats for Patient Safety Data Collection and Event Reporting

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-03-07

    ... Collection and Event Reporting AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice... voluntarily collect and submit standardized information regarding patient safety events. The purpose of this... report information regarding patient safety events and quality of care. Information that is assembled...

  2. 76 FR 7853 - Patient Safety Organizations: Voluntary Delisting From HealthDataPSO

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-02-11

    ... (Patient Safety Act), Public Law 109-41, 42 U.S.C. 299b-21--b-26, provides for the formation of PSOs, which... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary... from HealthDataPSO, a component entity of CCD Healthsystems and Medical Error Management, LLC, of...

  3. 77 FR 21776 - Announcement of Requirements and Registration for “Reporting Patient Safety Events Challenge”

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-04-11

    ... HUMAN SERVICES Announcement of Requirements and Registration for ``Reporting Patient Safety Events... busy physicians and nurses, and to create effective systems for the quality and risk management staff to do root cause analyses and follow-up. The ``Reporting Patient Safety Events Challenge'' asks...

  4. Efficacy and cutaneous safety of adapalene in black patients versus white patients with acne vulgaris.

    PubMed

    Czernielewski, Janusz; Poncet, Michel; Mizzi, Fabienne

    2002-10-01

    Acne vulgaris is the most common dermatologic disorder seen in American black patients (ie, African Americans and African Caribbeans, Fitzgerald skin types IV through VI). Despite its prevalence, there is a lack of data on the effects of treatments, such as the use of topical retinoids and retinoid analogs, in this patient population. Adapalene is a topical retinoid analog that has demonstrated efficacy in the reduction of noninflammatory and inflammatory lesions, along with excellent cutaneous tolerability. Most clinical studies of this agent have involved predominantly white patient populations. This meta-analysis of 5 randomized US and European studies was designed to evaluate the efficacy and safety of adapalene in black versus white patients. The percentage reduction in the number of inflammatory lesions was significantly greater among black patients compared with white patients (P=.012). The percentage reductions in total inflammatory and noninflammatory lesion counts were similar in the 2 groups (P>.3). There were significantly less erythema and scaling in black patients compared with white patients (P<.001 and P=.026 for worst scores for erythema and scaling, respectively). Although the incidence of dryness was similar in both groups, a smaller percentage of black than white patients had moderate or severe scores for dryness (7% vs 18%, respectively). In summary, adapalene appears to be a viable treatment for black patients with acne vulgaris.

  5. Violent Behavior in Cancer Patients--A Rarely Addressed Phenomenon in Oncological Treatment

    ERIC Educational Resources Information Center

    Grube, Michael

    2012-01-01

    Dealing with violent cancer patients can be particularly challenging. The purpose of this study was to collect data on the frequency, quality, and underlying variables affecting violent behavior as well as to examine the role played by this behavior in the premature interruption of treatment. A total of 388 cancer inpatients were examined by…

  6. Relationship between Patient Safety and Hospital Surgical Volume

    PubMed Central

    Hernandez-Boussard, Tina; Downey, John R; McDonald, Kathryn; Morton, John M

    2012-01-01

    Objective To examine the relationship between hospital volume and in-hospital adverse events. Data Sources Patient safety indicator (PSI) was used to identify hospital-acquired adverse events in the Nationwide Inpatient Sample database in abdominal aortic aneurysm, coronary artery bypass graft, and Roux-en-Y gastric bypass from 2005 to 2008. Study Design In this observational study, volume thresholds were defined by mean year-specific terciles. PSI risk-adjusted rates were analyzed by volume tercile for each procedure. Principal Findings Overall, hospital volume was inversely related to preventable adverse events. High-volume hospitals had significantly lower risk-adjusted PSI rates compared to lower volume hospitals (p < .05). Conclusion These data support the relationship between hospital volume and quality health care delivery in select surgical cases. This study highlights differences between hospital volume and risk-adjusted PSI rates for three common surgical procedures and highlights areas of focus for future studies to identify pathways to reduce hospital-acquired events. PMID:22091561

  7. A Novel Patient Safety Event Reporting Tool in Otolaryngology.

    PubMed

    Vila, Peter M; Lewis, Sean; Cunningham, Gene; Brereton, Jean; Espinel, Alexandra G; Roberson, David W; Shah, Rahul K

    2017-04-01

    Objective To report the results of a preliminary analysis of a quality improvement initiative aimed to identify potential latent systems defects. Methods A pilot study of an anonymous, voluntary, event reporting system made available to all members of the American Academy of Otolaryngology-Head and Neck Surgery was performed. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index was used to classify error types. Descriptive statistics were used to summarize submissions to the database. Results In the 53 cases reported to the database over 22 months, the majority involved errors that had resulted in harm (n = 34, 64%), followed by errors that occurred and did not result in harm (n = 7, 13%). Errors occurred predominantly in the hospital (n = 23, 44%) and operating room (n = 19, 35%). Most entries were classified as either technical (n = 21, 39%) or related to postoperative care (n = 15, 30%). Discussion This preliminary descriptive analysis of a novel otolaryngology patient safety event reporting tool shows that this platform brings unique value to the identification of errors and adverse events in our specialty. Most reported events were classified as errors resulting in harm. The most common type of reported event was a technical error, most often resulting in a nerve injury. Implications for Practice This reporting tool will likely allow for identification and prioritization of improvement opportunities. This example may serve as a guide for other societies to create similar platforms as we strive for a standardized process for event reporting.

  8. Organizational Silence and Hidden Threats to Patient Safety

    PubMed Central

    Henriksen, Kerm; Dayton, Elizabeth

    2006-01-01

    Organizational silence refers to a collective-level phenomenon of saying or doing very little in response to significant problems that face an organization. The paper focuses on some of the less obvious factors contributing to organizational silence that can serve as threats to patient safety. Converging areas of research from the cognitive, social, and organizational sciences and the study of sociotechnical systems help to identify some of the underlying factors that serve to shape and sustain organizational silence. These factors have been organized under three levels of analysis: (1) individual factors, including the availability heuristic, self-serving bias, and the status quo trap; (2) social factors, including conformity, diffusion of responsibility, and microclimates of distrust; and (3) organizational factors, including unchallenged beliefs, the good provider fallacy, and neglect of the interdependencies. Finally, a new role for health care leaders and managers is envisioned. It is one that places high value on understanding system complexity and does not take comfort in organizational silence. PMID:16898978

  9. In-Situ Radiological Surveys to Address Nuclear Criticality Safety Requirements During Remediation Activities at the Shallow Land Disposal Area, Armstrong County, Pennsylvania - 12268

    SciTech Connect

    Norris, Phillip; Mihalo, Mark; Eberlin, John; Lambert, Mike; Matthews, Brian

    2012-07-01

    Cabrera Services Inc. (CABRERA) is the remedial contractor for the Shallow Land Disposal Area (SLDA) Site in Armstrong County Pennsylvania, a United States (US) Army Corps of Engineers - Buffalo District (USACE) contract. The remediation is being completed under the USACE's Formerly Utilized Sites Remedial Action Program (FUSRAP) which was established to identify, investigate, and clean up or control sites previously used by the Atomic Energy Commission (AEC) and its predecessor, the Manhattan Engineer District (MED). As part of the management of the FUSRAP, the USACE is overseeing investigation and remediation of radiological contamination at the SLDA Site in accordance with the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA), 42 US Code (USC), Section 9601 et. seq, as amended and, the National Oil and Hazardous Substance Pollution Contingency Plan (NCP), Title 40 of the Code of Federal Regulations (CFR) Section 300.430(f) (2). The objective of this project is to clean up radioactive waste at SLDA. The radioactive waste contains special nuclear material (SNM), primarily U-235, in 10 burial trenches, Cabrera duties include processing, packaging and transporting the waste to an offsite disposal facility in accordance with the selected remedial alternative as defined in the Final Record of Decision (USACE, 2007). Of particular importance during the remediation is the need to address nuclear criticality safety (NCS) controls for the safe exhumation and management of waste containing fissile materials. The partnership between Cabrera Services, Inc. and Measutronics Corporation led to the development of a valuable survey tool and operating procedure that are essential components of the SLDA Criticality Safety and Material Control and Accountability programs. Using proven existing technologies in the design and manufacture of the Mobile Survey Cart, the continued deployment of the Cart will allow for an efficient and reliable methodology to

  10. A novel patient support program to address isotretinoin adherence: proof-of-concept analysis.

    PubMed

    Eichenfield, Lawrence F; Krakowski, Andrew C

    2015-04-01

    The iPLEDGE protocol for isotretinoin treatment requires multiple steps to be completed within strict timing windows, resulting in many interruptions or discontinuations of treatment. The US Food and Drug Administration has indicated that approximately 40% of isotretinoin prescriptions written over the course of one year of the iPLEDGE program were denied due to failure to comply with iPLEDGE. Insurance restrictions add to the likelihood of prescriptions not being filled. Here, we describe a novel program implemented specifically to assist patients and providers with improving isotretinoin therapy adherence. This innovative isotretinoin support program provides assistance with insurance questions and hurdles, an uninterrupted treatment supply, educational support, reminder communications, and an indigent patient assistance program. Proof-of-concept analysis shows that 17 months after implementation of the program, 93% of prescriptions received have been filled. Utilization of the program appears to improve adherence to an isotretinoin treatment regimen, with fewer interruptions due directly to unfilled prescriptions.

  11. The effects of organizational commitment and structural empowerment on patient safety culture.

    PubMed

    Horwitz, Sujin K; Horwitz, Irwin B

    2017-03-20

    Purpose The purpose of this paper is to investigate the relationship between patient safety culture and two attitudinal constructs: affective organizational commitment and structural empowerment. In doing so, the main and interaction effects of the two constructs on the perception of patient safety culture were assessed using a cohort of physicians. Design/methodology/approach Affective commitment was measured with the Organizational Commitment Questionnaire, whereas structural empowerment was assessed with the Conditions of Work Effectiveness Questionnaire-II. The abbreviated versions of these surveys were administered to a cohort of 71 post-doctoral medical residents. For the data analysis, hierarchical regression analyses were performed for the main and interaction effects of affective commitment and structural empowerment on the perception of patient safety culture. Findings A total of 63 surveys were analyzed. The results revealed that both affective commitment and structural empowerment were positively related to patient safety culture. A potential interaction effect of the two attitudinal constructs on patient safety culture was tested but no such effect was detected. Research limitations/implications This study suggests that there are potential benefits of promoting affective commitment and structural empowerment for patient safety culture in health care organizations. By identifying the positive associations between the two constructs and patient safety culture, this study provides additional empirical support for Kanter's theoretical tenet that structural and organizational support together helps to shape the perceptions of patient safety culture. Originality/value Despite the wide recognition of employee empowerment and commitment in organizational research, there has still been a paucity of empirical studies specifically assessing their effects on patient safety culture in health care organizations. To the authors' knowledge, this study is the first

  12. A survey of nurses’ awareness of patient safety culture in neonatal intensive care units

    PubMed Central

    Hemmat, Faezeh; Atashzadeh-Shoorideh, Foroozan; Mehrabi, Tayebeh; Zayeri, Farid

    2015-01-01

    Background: Patient safety is considered as the most important quality for healthcare. One of the main factors that play an important role in the promotion of healthcare institutes is patient safety. This study describes the nurses’ awareness of patient safety culture in neonatal intensive care units (NICUs). Materials and Methods: In this descriptive study, 83 nurses working in neonatal intensive care units of hospitals affiliated to Isfahan University of Medical Sciences, Iran, were selected using purposive sampling. Data collection tools consisted of the demographic characteristics questionnaire and the Hospital Survey on Patient Safety Culture. Data were analyzed by using SPSS software. Results: The dimension that received the highest positive response rate was “expectations and actions of the supervisor/manager in promoting safety culture.” The dimension with the lowest percentage of positive responses was “frequency of error reporting.” 21.70% of the NICU nurses reported one or two incidents in their work units in the previous 12 months. Conclusions: In order to create and promote patient safety, appropriate management of resources and a correct understanding of patient safety culture are required. In this way, awareness of dimensions which are not acceptable provides the basic information necessary for improving patient safety. PMID:26257806

  13. Integrating patient safety into health professionals’ curricula: a qualitative study of medical, nursing and pharmacy faculty perspectives

    PubMed Central

    Tregunno, Deborah; Ginsburg, Liane; Clarke, Beth; Norton, Peter

    2014-01-01

    Background As efforts to integrate patient safety into health professional curricula increase, there is growing recognition that the rate of curricular change is very slow, and there is a shortage of research that addresses critical perspectives of faculty who are on the ‘front-lines’ of curricular innovation. This study reports on medical, nursing and pharmacy teaching faculty perspectives about factors that influence curricular integration and the preparation of safe practitioners. Methods Qualitative methods were used to collect data from 20 faculty members (n=6 medical from three universities; n=6 pharmacy from two universities; n=8 nursing from four universities) engaged in medical, nursing and pharmacy education. Thematic analysis generated a comprehensive account of faculty perspectives. Results Faculty perspectives on key challenges to safe practice vary across the three disciplines, and these different perspectives lead to different priorities for curricular innovation. Additionally, accreditation and regulatory requirements are driving curricular change in medicine and pharmacy. Key challenges exist for health professional students in clinical teaching environments where the culture of patient safety may thwart the preparation of safe practitioners. Conclusions Patient safety curricular innovation depends on the interests of individual faculty members and the leveraging of accreditation and regulatory requirements. Building on existing curricular frameworks, opportunities now need to be created for faculty members to act as champions of curricular change, and patient safety educational opportunities need to be harmonises across all health professional training programmes. Faculty champions and practice setting leaders can collaborate to improve the culture of patient safety in clinical teaching and learning settings. PMID:24299734

  14. Patient Safety: What You Can Do to Be a Safe Patient

    MedlinePlus

    ... HICPAC Injection Safety Medication Safety Program MRSA NHSN Nursing Homes and Assisted Living (Long-term Care Facilities) Sepsis ... Safety One & Only Campaign Medication Safety MRSA Information Nursing Homes and Assisted Living: Resident Information Speak Up Initiatives ...

  15. Aviation and healthcare: a comparative review with implications for patient safety

    PubMed Central

    Parand, Anam; Soukup, Tayana; Reader, Tom; Sevdalis, Nick

    2015-01-01

    Safety in aviation has often been compared with safety in healthcare. Following a recent article in this journal, the UK government set up an Independent Patient Safety Investigation Service, to emulate a similar well-established body in aviation. On the basis of a detailed review of relevant publications that examine patient safety in the context of aviation practice, we have drawn up a table of comparative features and a conceptual framework for patient safety. Convergence and divergence of safety-related behaviours across aviation and healthcare were derived and documented. Key safety-related domains that emerged included Checklists, Training, Crew Resource Management, Sterile Cockpit, Investigation and Reporting of Incidents and Organisational Culture. We conclude that whilst healthcare has much to learn from aviation in certain key domains, the transfer of lessons from aviation to healthcare needs to be nuanced, with the specific characteristics and needs of healthcare borne in mind. On the basis of this review, it is recommended that healthcare should emulate aviation in its resourcing of staff who specialise in human factors and related psychological aspects of patient safety and staff wellbeing. Professional and post-qualification staff training could specifically include Cognitive Bias Avoidance Training, as this appears to play a key part in many errors relating to patient safety and staff wellbeing. PMID:26770817

  16. Human factors and systems engineering approach to patient safety for radiotherapy.

    PubMed

    Rivera, A Joy; Karsh, Ben-Tzion

    2008-01-01

    The traditional approach to solving patient safety problems in healthcare is to blame the last person to touch the patient. But since the publication of To Err is Human, the call has been instead to use human factors and systems engineering methods and principles to solve patient safety problems. However, an understanding of the human factors and systems engineering is lacking, and confusion remains about what it means to apply their principles. This paper provides a primer on them and their applications to patient safety.

  17. Patient safety, error reduction, and pediatric nurses' perceptions of smart pump technology.

    PubMed

    Mason, Janice Jackson; Roberts-Turner, Renée; Amendola, Virginia; Sill, Anne M; Hinds, Pamela S

    2014-01-01

    Patient safety and error reduction are essential to improve patient care, and new technology is expected to contribute to such improvements while reducing costs and increasing care efficiency in health care organizations. The purpose of this study was to assess the relationships among pediatric nurses' perceptions of smart infusion pump (SIP) technology, patient safety, and error reduction. Findings revealed that RNs' perceptions of SIP correlated with patient safety. No significant relationship was found between RNs' perceptions of SIP and error reduction, but data retrieved from the pumps revealed 93 manipulations of the pumps, of which error reduction was captured 65 times.

  18. Addressing hospital-acquired pressure ulcers: patient care managers enhancing outcomes at the point of service.

    PubMed

    Frumenti, Jeanine M; Kurtz, Abby

    2014-01-01

    An innovative leadership training program for patient care managers (PCMs) aimed at improving the management of operational failures was conducted at a large metropolitan hospital center. The program focused on developing and enhancing the transformational leadership skills of PCMs by improving their ability to manage operational failures in general and, in this case, hospital-acquired pressure ulcers. The PCMs received 8 weeks of intense training using the Toyota Production System process improvement approach, along with executive coaching. Compared with the control group, the gains made by the intervention group were statistically significant.

  19. Effects of auditing patient safety in hospital care: design of a mixed-method evaluation

    PubMed Central

    2013-01-01

    Background Auditing of patient safety aims at early detection of risks of adverse events and is intended to encourage the continuous improvement of patient safety. The auditing should be an independent, objective assurance and consulting system. Auditing helps an organisation accomplish its objectives by bringing a systematic, disciplined approach to evaluating and improving the effectiveness of risk management, control, and governance. Audits are broadly conducted in hospitals, but little is known about their effects on the behaviour of healthcare professionals and patient safety outcomes. This study was initiated to evaluate the effects of patient safety auditing in hospital care and to explore the processes and mechanisms underlying these effects. Methods and design Our study aims to evaluate an audit system to monitor and improve patient safety in a hospital setting. We are using a mixed-method evaluation with a before-and-after study design in eight departments of one university hospital in the period October 2011–July 2014. We measure several outcomes 3 months before the audit and 15 months after the audit. The primary outcomes are adverse events and complications. The secondary outcomes are experiences of patients, the standardised mortality ratio, prolonged hospital stay, patient safety culture, and team climate. We use medical record reviews, questionnaires, hospital administrative data, and observations to assess the outcomes. A process evaluation will be used to find out which components of internal auditing determine the effects. Discussion We report a study protocol of an effect and process evaluation to determine whether auditing improves patient safety in hospital care. Because auditing is a complex intervention targeted on several levels, we are using a combination of methods to collect qualitative and quantitative data about patient safety at the patient, professional, and department levels. This study is relevant for hospitals that want to

  20. Addressing the unmet needs of patients with persistent negative symptoms of schizophrenia: emerging pharmacological treatment options

    PubMed Central

    Chue, Pierre; Lalonde, Justine K

    2014-01-01

    The negative symptoms of schizophrenia represent an impairment of normal emotional responses, thought processes and behaviors, and include blunting or flattening of affect, alogia/aprosody, avolition/apathy, anhedonia, and asociality. Negative symptoms contribute to a reduced quality of life, increased functional disability, increased burden of illness, and poorer long-term outcomes, to a greater degree than positive symptoms. Primary negative symptoms are prominent and persistent in up to 26% of patients with schizophrenia, and they are estimated to occur in up to 58% of outpatients at any given time. Negative symptoms respond less well to medications than positive symptoms, and to date treatment options for negative symptoms have been limited, with no accepted standard treatment. Modest benefits have been reported with a variety of different agents, including second-generation antipsychotics and add-on therapy with antidepressants and other pharmacological classes. Recent clinical research focusing on negative symptoms target novel biological systems, such as glutamatergic neurotransmission. Different approaches include: enhancing N-methyl-D-aspartate receptor function with agents that bind directly to the glycine ligand site or with glycine reuptake inhibitors; influencing the metabotropic glutamate receptor (mGluR2/3) with positive allosteric modulators; and stimulating nicotinic acetylcholine receptors. In conclusion, the lack of clearly efficacious pharmacological treatments for the management of negative symptoms represents a significant unmet need, especially considering the importance of these symptoms on patient outcomes. Hence, further research to identify and characterize novel pharmacological treatments for negative symptoms is greatly needed. PMID:24855363

  1. Safety.

    ERIC Educational Resources Information Center

    Education in Science, 1996

    1996-01-01

    Discusses safety issues in science, including: allergic reactions to peanuts used in experiments; explosions in lead/acid batteries; and inspection of pressure vessels, such as pressure cookers or model steam engines. (MKR)

  2. Orienting patients to greater opioid safety: models of community pharmacy-based naloxone.

    PubMed

    Green, Traci C; Dauria, Emily F; Bratberg, Jeffrey; Davis, Corey S; Walley, Alexander Y

    2015-08-06

    The leading cause of adult injury death in the U.S.A. is drug overdose, the majority of which involves prescription opioid medications. Outside of the U.S.A., deaths by drug overdose are also on the rise, and overdose is a leading cause of death for drug users. Reducing overdose risk while maintaining access to prescription opioids when medically indicated requires careful consideration of how opioids are prescribed and dispensed, how patients use them, how they interact with other medications, and how they are safely stored. Pharmacists, highly trained professionals expert at detecting and managing medication errors and drug-drug interactions, safe dispensing, and patient counseling, are an under-utilized asset in addressing overdose in the U.S. and globally. Pharmacies provide a high-yield setting where patient and caregiver customers can access naloxone-an opioid antagonist that reverses opioid overdose-and overdose prevention counseling. This case study briefly describes and provides two US state-specific examples of innovative policy models of pharmacy-based naloxone, implemented to reduce overdose events and improve opioid safety: Collaborative Pharmacy Practice Agreements and Pharmacy Standing Orders.

  3. Organization and Representation of Patient Safety Data: Current Status and Issues around Generalizability and Scalability

    PubMed Central

    Boxwala, Aziz A.; Dierks, Meghan; Keenan, Maura; Jackson, Susan; Hanscom, Robert; Bates, David W.; Sato, Luke

    2004-01-01

    Recent reports have identified medical errors as a significant cause of morbidity and mortality among patients. A variety of approaches have been implemented to identify errors and their causes. These approaches include retrospective reporting and investigation of errors and adverse events and prospective analyses for identifying hazardous situations. The above approaches, along with other sources, contribute to data that are used to analyze patient safety risks. A variety of data structures and terminologies have been created to represent the information contained in these sources of patient safety data. Whereas many representations may be well suited to the particular safety application for which they were developed, such application-specific and often organization-specific representations limit the sharability of patient safety data. The result is that aggregation and comparison of safety data across organizations, practice domains, and applications is difficult at best. A common reference data model and a broadly applicable terminology for patient safety data are needed to aggregate safety data at the regional and national level and conduct large-scale studies of patient safety risks and interventions. PMID:15298992

  4. Addressing Missing Data in Patient-Reported Outcome Measures (PROMS): Implications for the Use of PROMS for Comparing Provider Performance.

    PubMed

    Gomes, Manuel; Gutacker, Nils; Bojke, Chris; Street, Andrew

    2016-05-01

    Patient-reported outcome measures (PROMs) are now routinely collected in the English National Health Service and used to compare and reward hospital performance within a high-powered pay-for-performance scheme. However, PROMs are prone to missing data. For example, hospitals often fail to administer the pre-operative questionnaire at hospital admission, or patients may refuse to participate or fail to return their post-operative questionnaire. A key concern with missing PROMs is that the individuals with complete information tend to be an unrepresentative sample of patients within each provider and inferences based on the complete cases will be misleading. This study proposes a strategy for addressing missing data in the English PROM survey using multiple imputation techniques and investigates its impact on assessing provider performance. We find that inferences about relative provider performance are sensitive to the assumptions made about the reasons for the missing data.

  5. Use of evidence-based data to drive your patient safety program.

    PubMed

    Meyer, Gregg S; Rall, Christina

    2002-08-01

    The Agency for Health Care Research and Quality (AHRQ) is committed to conducting and supporting health services research and promoting technical improvements that enhance the quality of health care delivered in the United States. A significant focus of AHRQ's efforts has been its work on patient safety, and it had depended on numerous collaborative efforts both inside and outside of the federal government to exponentially increase what it could accomplish alone. In 2001 fiscal year, Congress appropriated $50 million for the AHRQ's patient safety research initiatives that were collectively aimed at expanding the nation's capacity to conduct research in this field. The portfolio is guided by a user-driven patient safety research agenda that was developed at the September 2000 National Summit on Medical Errors and Patient Safety Research. The research results generated by this initiative will provide an evidentiary base for system improvements that, when implemented, will greatly enhance the safety of the nation's health care system.

  6. Crew resource management improved perception of patient safety in the operating room.

    PubMed

    Gore, Dennis C; Powell, Jennifer M; Baer, Jennifer G; Sexton, Karen H; Richardson, C Joan; Marshall, David R; Chinkes, David L; Townsend, Courtney M

    2010-01-01

    To improve safety in the operating theater, a company of aviation pilots was employed to guide implementation of preprocedural briefings. A 5-point Likert scale survey that assessed the attitudes of operating room personnel toward patient safety was distributed before and 6 months following implementation of the briefings. Using Mann-Whitney analysis, the survey showed a significant (P < .05) improvement in 2 questions (of 13) involving reporting error and 2 questions (of 11) involving patient safety climate. When analyzed by occupation, there were no significant changes for faculty physicians; for resident physicians, there was a significant improvement in 1 question (of 13) regarding error reporting. For nurses, there were significant improvements in 3 questions (of 4) involving teamwork, 1 question (of 13) involving reporting error, and 3 questions (of 11) regarding patient safety climate. These results suggest that aviation-based crew resource management initiatives lead to an improved perception of patient safety, which was largely demonstrated by nursing personnel.

  7. Effects of a senior practicum course on nursing students' confidence in speaking up for patient safety.

    PubMed

    Kent, Lauren; Anderson, Gabrielle; Ciocca, Rebecca; Shanks, Linda; Enlow, Michele

    2015-03-01

    As patient advocates, nurses are responsible for speaking up against unsafe practices. Nursing students must develop the confidence to speak up for patient safety so that they can hold themselves, as well as their peers and coworkers, accountable for patients' well-being. The purpose of this study was to examine the effects of a senior practicum course on confidence for speaking up for patient safety in nursing students. Confidence in speaking up for patient safety was measured with the Health Professional Education in Patient Safety Survey. The study showed a significant increase in nursing students' confidence after the senior practicum course, but there was no significant change in students' confidence in questioning someone of authority.

  8. Cognitive performance-altering effects of electronic medical records: An application of the human factors paradigm for patient safety

    PubMed Central

    Holden, Richard J.

    2010-01-01

    According to the human factors paradigm for patient safety, health care work systems and innovations such as electronic medical records do not have direct effects on patient safety. Instead, their effects are contingent on how the clinical work system, whether computerized or not, shapes health care providers' performance of cognitive work processes. An application of the human factors paradigm to interview data from two hospitals in the Midwest United States yielded numerous examples of the performance-altering effects of electronic medical records, electronic clinical documentation, and computerized provider order entry. Findings describe both improvements and decrements in the ease and quality of cognitive performance, both for interviewed clinicians and for their colleagues and patients. Changes in cognitive performance appear to have desirable and undesirable implications for patient safety as well as for quality of care and other important outcomes. Cognitive performance can also be traced to interactions between work system elements, including new technology, allowing for the discovery of problems with “fit” to be addressed through design interventions. PMID:21479125

  9. Specimen rejection in laboratory medicine: Necessary for patient safety?

    PubMed Central

    Dikmen, Zeliha Gunnur; Pinar, Asli; Akbiyik, Filiz

    2015-01-01

    Introduction The emergency laboratory in Hacettepe University Hospitals receives specimens from emergency departments (EDs), inpatient services and intensive care units (ICUs). The samples are accepted according to the rejection criteria of the laboratory. In this study, we aimed to evaluate the sample rejection ratios according to the types of pre-preanalytical errors and collection areas. Materials and methods The samples sent to the emergency laboratory were recorded during 12 months between January to December, 2013 in which 453,171 samples were received and 27,067 specimens were rejected. Results Rejection ratios was 2.5% for biochemistry tests, 3.2% for complete blood count (CBC), 9.8% for blood gases, 9.2% for urine analysis, 13.3% for coagulation tests, 12.8% for therapeutic drug monitoring, 3.5% for cardiac markers and 12% for hormone tests. The most frequent rejection reasons were fibrin clots (28%) and inadequate volume (9%) for biochemical tests. Clotted samples (35%) and inadequate volume (13%) were the major causes for coagulation tests, blood gas analyses and CBC. The ratio of rejected specimens was higher in the EDs (40%) compared to ICUs (30%) and inpatient services (28%). The highest rejection ratio was observed in neurology ICU (14%) among the ICUs and internal medicine inpatient service (10%) within inpatient clinics. Conclusions We detected an overall specimen rejection rate of 6% in emergency laboratory. By documentation of rejected samples and periodic training of healthcare personnel, we expect to decrease sample rejection ratios below 2%, improve total quality management of the emergency laboratory and promote patient safety. PMID:26527231

  10. [Is an effort needed in order to replace the punitive culture for the sake of patient safety?].

    PubMed

    Gutiérrez Ubeda, S R

    2016-01-01

    Efforts to introduce a safety culture have flourished in a growing number of health care organisations. However, many of these organisational efforts have been incomplete with respect to the manner on how to address the resistance to change offered by the prevailing punitive culture of healthcare organisations. The present article is intended to increase the awareness on three reasons of why an effort is needed to change the punitive culture before introducing the patient safety culture. The first reason is that the culture needs to be investigated and understood. The second reason is that culture is a complex construct, deeply embedded in organisations and their contexts, and thus difficult to change. The third reason is that punitive culture is not compatible with some components of safety culture, thus without removing it there are great possibilities that it would continue to be active and dominant over safety culture. These reasons suggest that, unless planning and executing effective interventions towards replacing punitive culture with safety culture, there is the risk that punitive culture would still prevail.

  11. Obstetrician/gynecologist hospitalists: can we improve safety and outcomes for patients and hospitals and improve lifestyle for physicians?

    PubMed

    Olson, Rob; Garite, Thomas J; Fishman, Alan; Andress, Ianthe F

    2012-08-01

    Over the last 5 years, a new obstetric-gynecologic hospitalist model has emerged rapidly, the primary focus of which is the care and safety of the laboring patient. The need for this type of practitioner has been driven by a number of factors: various types of patient safety programs that require a champion and organizer; the realization that bad outcomes and malpractice lawsuits often result from the lack of immediate availability of a physician in the labor and delivery suite; the desire for many younger practicing physicians to seek a balance between their personal and professional lives; the appeal of shift work as opposed to running a busy private practice; the waning amount of training that new residency graduates receive in critical skills that are needed on labor and delivery; the void in critical care of the laboring patient that is created by the outpatient focus of many physicians in maternal-fetal medicine; the need for hospitals to have a group of physicians to implement protocols and policies on the unit, and the need for teaching in all hospitals, not just academic centers. By having a dedicated group of physicians whose practice is limited mostly to the care of the labor and delivery aspects of patient care, there is great potential to address many of these needs. There are currently 164 known obstetrician/gynecologist hospitalist programs across the United States, with 2 more coming on each month; the newly formed Society of Obstetrician/Gynecologist Hospitalists currently has >80 individual members. This article addresses the advantages, challenges, and variety of Hospitalist models and will suggest that what may be considered an emerging trend is actually a sustainable model for improved patient care and safety.

  12. Patient Safety in Obstetrics and Gynecology Departments of two Teaching Hospitals in Delhi

    PubMed Central

    Gupta, Bindiya; Guleria, Kiran; Arora, Renu

    2016-01-01

    Background: A healthy safety culture is integral to positive health care. A sound safety climate is required in Obstetrics and Gynecology to prevent adverse outcomes. Objective: The objective of this study was to assess and compare patient safety culture in two departments of Obstetrics and Gynecology. Materials and Methods: Using a closed-ended standard version of Hospital Survey on Patient Safety Culture (HSOPS), respondents were asked to answer 42 survey items, grouped into 10 dimensions and two outcome variables in two tertiary care teaching hospitals in Delhi. Qualitative data were compared using Fisher's exact test and chi-square test wherever applicable. Mean values were calculated and compared using unpaired t-test. Results: The overall survey response rate was 55%. A positive response rate of 57% was seen in the overall perception of patient safety that ranged from very good to acceptable. Sixty-four percent showed positive teamwork across hospital departments and units, while 36% gave an affirmative opinion with respect to interdepartmental handoffs. However, few adverse events (0-10) were reported in the last 12 months and only 38% of mistakes by doctors were reported. Half of the respondents agreed that their mistakes were held against them. There was no statistical difference in the safety culture between the two hospitals. Conclusions: Although the perception of patient safety and standards of patient safety were high in both the hospitals' departments, there is plenty of scope for improvement with respect to event reporting, positive feedback, and nonpunitive error. PMID:27385879

  13. Initial implementation of mixed reality simulation targeting teamwork and patient safety.

    PubMed

    Kozmenko, Valeriy; Paige, John; Chauvin, Sheila

    2008-01-01

    Patient safety is one of the most pressing challenges of modern healthcare. Being a multifactorial problem, patient safety requires improvement interventions on multiple levels including individual, team and organization as a whole. Using high-fidelity human patient simulator in real clinical setting allows creating a mixed reality environment for teaching healthcare teams to improve patient safety. A multidisciplinary group of physicians at Louisiana State University Health Sciences Center in New Orleans has developed and implemented the STEPS program (System for Teamwork Effectiveness and Patient Safety) with the use of MMOR (mobile mock operating room) configuration to train general surgical teams within their own operating room environment. Each simulation session was followed by facilitated debriefing and teaching new team communication skills. Team performances were assessed by both direct observation and team's self-assessment where each team member assessed his or her own performance as well as the performance of all other team members (360 degree assessment).

  14. The Helsinki Declaration on Patient Safety in Anaesthesiology: putting words into practice.

    PubMed

    Whitaker, David K; Brattebø, Guttorm; Smith, Andrew F; Staender, Sven E A

    2011-06-01

    In June 2010, the European Board of Anaesthesiology (EBA) of the European Union of Medical Specialists (UEMS) and the European Society of Anaesthesiology (ESA) signed the Helsinki Declaration for Patient Safety in Anaesthesiology at the Euroanaesthesia meeting in Helsinki. The document had been jointly prepared by these two principal anaesthesiology organisations in Europe who pledged to improve the safety of patients being cared for by anaesthesiologists working in the medical fields of perioperative care, intensive care medicine, emergency medicine and pain medicine. The declaration stated their current heads of agreement on patient safety and listed a number of principle requirements as thought necessary for anaesthesiologists, anaesthesiology departments and institutions to introduce to improve patient safety. Good words are only as good as their implementation and this article explains the rationale behind them and expands the recommendations practically so anaesthesiologists caring for patients everywhere can follow the Helsinki Declaration and put the words into practice.

  15. [How patient safety programmes can be successfully implemented - an example from Switzerland].

    PubMed

    Kobler, Irene; Mascherek, Anna; Bezzola, Paula

    2015-01-01

    Internationally, the implementation of patient safety programmes poses a major challenge. In the first part, we will demonstrate that various measures have been found to be effective in the literature but that they often do not reach the patient because their implementation proves difficult. Difficulties arise from both the complexity of the interventions themselves and from different organisational settings in individual hospitals. The second part specifically describes the implementation of patient safety improvement programmes in Switzerland and discusses measures intended to bridge the gap between the theory and practice of implementation in Switzerland. Then, the national pilot programme to improve patient safety in surgery is presented, which was launched by the federal Swiss government and has been implemented by the patient safety foundation. Procedures, challenges and highlights in implementing the programme in Switzerland on a national level are outlined. Finally, first (preliminary) results are presented and critically discussed.

  16. How Baccalaureate Nursing Students Value an Interprofessional Patient Safety Course for Professional Development

    PubMed Central

    Abbott, Amy A.; Fuji, Kevin T.; Galt, Kimberly A.; Paschal, Karen A.

    2012-01-01

    Nursing students need foundation knowledge and skills to keep patients safe in continuously changing health care environments. A gap exists in our knowledge of the value students place on interprofessional patient safety education. The purpose of this exploratory, mixed methods study was to understand nursing students' attitudes about the value of an interprofessional patient safety course to their professional development and its role in health professions curricula. Qualitative and quantitative data were collected from formative course performance measures, course evaluations, and interviews with six nursing students. The qualitative themes of awareness, ownership, and action emerged and triangulated with the descriptive quantitative results from student performance and course evaluations. Students placed high value on the course and essential nature of interprofessional patient safety content. These findings provide a first step toward integration of interprofessional patient safety education into nursing curricula and in meeting the Institute of Medicine's goals for the nursing profession. PMID:22523700

  17. The Effect of a Freely Available Flipped Classroom Course on Health Care Worker Patient Safety Culture: A Prospective Controlled Study

    PubMed Central

    Ling, Lowell; Gomersall, Charles David; Samy, Winnie; Joynt, Gavin Matthew; Leung, Czarina CH; Wong, Wai-Tat

    2016-01-01

    Background Patient safety culture is an integral aspect of good standard of care. A good patient safety culture is believed to be a prerequisite for safe medical care. However, there is little evidence on whether general education can enhance patient safety culture. Objective Our aim was to assess the impact of a standardized patient safety course on health care worker patient safety culture. Methods Health care workers from Intensive Care Units (ICU) at two hospitals (A and B) in Hong Kong were recruited to compare the changes in safety culture before and after a patient safety course. The BASIC Patient Safety course was administered only to staff from Hospital A ICU. Safety culture was assessed in both units at two time points, one before and one after the course, by using the Hospital Survey on Patient Safety Culture questionnaire. Responses were coded according to the Survey User’s Guide, and positive response percentages for each patient safety domain were compared to the 2012 Agency for Healthcare Research and Quality ICU sample of 36,120 respondents. Results We distributed 127 questionnaires across the two hospitals with an overall response rate of 74.8% (95 respondents). After the safety course, ICU A significantly improved on teamwork within hospital units (P=.008) and hospital management support for patient safety (P<.001), but decreased in the frequency of reporting mistakes compared to the initial survey (P=.006). Overall, ICU A staff showed significantly greater enhancement in positive responses in five domains than staff from ICU B. Pooled data indicated that patient safety culture was poorer in the two ICUs than the average ICU in the Agency for Healthcare Research and Quality database, both overall and in every individual domain except hospital management support for patient safety and hospital handoffs and transitions. Conclusions Our study demonstrates that a structured, reproducible short course on patient safety may be associated with an

  18. Patient safety in anesthesia: learning from the culture of high-reliability organizations.

    PubMed

    Wright, Suzanne M

    2015-03-01

    There has been an increased awareness of and interest in patient safety and improved outcomes, as well as a growing body of evidence substantiating medical error as a leading cause of death and injury in the United States. According to The Joint Commission, US hospitals demonstrate improvements in health care quality and patient safety. Although this progress is encouraging, much room for improvement remains. High-reliability organizations, industries that deliver reliable performances in the face of complex working environments, can serve as models of safety for our health care system until plausible explanations for patient harm are better understood.

  19. The “To Err is Human” report and the patient safety literature

    PubMed Central

    Stelfox, H T; Palmisani, S; Scurlock, C; Orav, E J; Bates, D W

    2006-01-01

    Background The “To Err is Human” report published by the Institute of Medicine (IOM) in 1999 called for a national effort to make health care safer. Although the report has been widely credited with spawning efforts to study and improve safety in health care, there has been limited objective assessment of its impact. We evaluated the effects of the IOM report on patient safety publications and research awards. Methods We searched MEDLINE to identify English language articles on patient safety and medical errors published between 1 November 1994 and 1 November 2004. Using interrupted time series analyses, changes in the number, type, and subject matter of patient safety publications were measured. We also examined federal (US only) funding of patient safety research awards for the fiscal years 1995–2004. Results A total of 5514 articles on patient safety and medical errors were published during the 10 year study period. The rate of patient safety publications increased from 59 to 164 articles per 100 000 MEDLINE publications (p<0.001) following the release of the IOM report. Increased rates of publication were observed for all types of patient safety articles. Publications of original research increased from an average of 24 to 41 articles per 100 000 MEDLINE publications after the release of the report (p<0.001), while patient safety research awards increased from 5 to 141 awards per 100 000 federally funded biomedical research awards (p<0.001). The most frequent subject of patient safety publications before the IOM report was malpractice (6% v 2%, p<0.001) while organizational culture was the most frequent subject (1% v 5%, p<0.001) after publication of the report. Conclusions Publication of the report “To Err is Human” was associated with an increased number of patient safety publications and research awards. The report appears to have stimulated research and discussion about patient safety issues, but whether this will translate into safer

  20. Using Active Learning to Identify Health Information Technology Related Patient Safety Events.

    PubMed

    Fong, Allan; Howe, Jessica L; Adams, Katharine T; Ratwani, Raj M

    2017-01-18

    The widespread adoption of health information technology (HIT) has led to new patient safety hazards that are often difficult to identify. Patient safety event reports, which are self-reported descriptions of safety hazards, provide one view of potential HIT-related safety events. However, identifying HIT-related reports can be challenging as they are often categorized under other more predominate clinical categories. This challenge of identifying HIT-related reports is exacerbated by the increasing number and complexity of reports which pose challenges to human annotators that must manually review reports. In this paper, we apply active learning techniques to support classification of patient safety event reports as HIT-related. We evaluated different strategies and demonstrated a 30% increase in average precision of a confirmatory sampling strategy over a baseline no active learning approach after 10 learning iterations.

  1. Annotated Bibliography: Understanding Ambulatory Care Practices in the Context of Patient Safety and Quality Improvement.

    PubMed

    Montano, Maria F; Mehdi, Harshal; Nash, David B

    2016-11-01

    The ambulatory care setting is an increasingly important component of the patient safety conversation. Inpatient safety is the primary focus of the vast majority of safety research and interventions, but the ambulatory setting is actually where most medical care is administered. Recent attention has shifted toward examining ambulatory care in order to implement better health care quality and safety practices. This annotated bibliography was created to analyze and augment the current literature on ambulatory care practices with regard to patient safety and quality improvement. By providing a thorough examination of current practices, potential improvement strategies in ambulatory care health care settings can be suggested. A better understanding of the myriad factors that influence delivery of patient care will catalyze future health care system development and implementation in the ambulatory setting.

  2. Sensemaking and the co-production of safety: a qualitative study of primary medical care patients.

    PubMed

    Rhodes, Penny; McDonald, Ruth; Campbell, Stephen; Daker-White, Gavin; Sanders, Caroline

    2016-02-01

    This study explores the ways in which patients make sense of 'safety' in the context of primary medical care. Drawing on qualitative interviews with primary care patients, we reveal patients' conceptualisation of safety as fluid, contingent, multi-dimensional, and negotiated. Participant accounts drew attention to a largely invisible and inaccessible (but taken for granted) architecture of safety, the importance of psycho-social as well as physical dimensions and the interactions between them, informal strategies for negotiating safety, and the moral dimension of safety. Participants reported being proactive in taking action to protect themselves from potential harm. The somewhat routinised and predictable nature of the primary medical care consultation, which is very different from 'one off' inpatient spells, meant that patients were not passive recipients of care. Instead they had a stock of accumulated knowledge and experience to inform their actions. In addition to highlighting the differences and similarities between hospital and primary care settings, the study suggests that a broad conceptualisation of patient safety is required, which encompasses the safety concerns of patients in primary care settings.

  3. 77 FR 32975 - Patient Safety Organizations: Expired Listing for The American Cancer Biorepository, Inc. d/b/a...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-06-04

    ... HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Expired Listing...'' AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice of delisting. SUMMARY... Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorizes the listing of...

  4. Modeling the hospital safety partnership preferences of patients and their families: a discrete choice conjoint experiment

    PubMed Central

    Cunningham, Charles E; Hutchings, Tracy; Henderson, Jennifer; Rimas, Heather; Chen, Yvonne

    2016-01-01

    Background Patients and their families play an important role in efforts to improve health service safety. Objective The objective of this study is to understand the safety partnership preferences of patients and their families. Method We used a discrete choice conjoint experiment to model the safety partnership preferences of 1,084 patients or those such as parents acting on their behalf. Participants made choices between hypothetical safety partnerships composed by experimentally varying 15 four-level partnership design attributes. Results Participants preferred an approach to safety based on partnerships between patients and staff rather than a model delegating responsibility for safety to hospital staff. They valued the opportunity to participate in point of service safety partnerships, such as identity and medication double checks, that might afford an immediate risk reduction. Latent class analysis yielded two segments. Actively engaged participants (73.3%) comprised outpatients with higher education, who anticipated more benefits to safety partnerships, were more confident in their ability to contribute, and were more intent on participating. They were more likely to prefer a personal engagement strategy, valued scientific evidence, preferred a more active approach to safety education, and advocated disclosure of errors. The passively engaged segment (26.7%) anticipated fewer benefits, were less confident in their ability to contribute, and were less intent on participating. They were more likely to prefer an engagement strategy based on signage. They preferred that staff explain why they thought patients should help make care safer and decide whether errors were disclosed. Inpatients, those with immigrant backgrounds, and those with less education were more likely to be in this segment. Conclusion Health services need to communicate information regarding risks, ask about partnership preferences, create opportunities respecting individual differences, and

  5. Design and Testing of the Safety Agenda Mobile App for Managing Health Care Managers’ Patient Safety Responsibilities

    PubMed Central

    Carrillo, Irene; Fernandez, Cesar; Vicente, Maria Asuncion; Guilabert, Mercedes

    2016-01-01

    Background Adverse events are a reality in clinical practice. Reducing the prevalence of preventable adverse events by stemming their causes requires health managers’ engagement. Objective The objective of our study was to develop an app for mobile phones and tablets that would provide managers with an overview of their responsibilities in matters of patient safety and would help them manage interventions that are expected to be carried out throughout the year. Methods The Safety Agenda Mobile App (SAMA) was designed based on standardized regulations and reviews of studies about health managers’ roles in patient safety. A total of 7 managers used a beta version of SAMA for 2 months and then they assessed and proposed improvements in its design. Their experience permitted redesigning SAMA, improving functions and navigation. A total of 74 Spanish health managers tried out the revised version of SAMA. After 4 months, their assessment was requested in a voluntary and anonymous manner. Results SAMA is an iOS app that includes 37 predefined tasks that are the responsibility of health managers. Health managers can adapt these tasks to their schedule, add new ones, and share them with their team. SAMA menus are structured in 4 main areas: information, registry, task list, and settings. Of the 74 users who tested SAMA, 64 (86%) users provided a positive assessment of SAMA characteristics and utility. Over an 11-month period, 238 users downloaded SAMA. This mobile app has obtained the AppSaludable (HealthyApp) Quality Seal. Conclusions SAMA includes a set of activities that are expected to be carried out by health managers in matters of patient safety and contributes toward improving the awareness of their responsibilities in matters of safety. PMID:27932315

  6. Integrated care: an Information Model for Patient Safety and Vigilance Reporting Systems.

    PubMed

    Rodrigues, Jean-Marie; Schulz, Stefan; Souvignet, Julien

    2015-01-01

    Quality management information systems for safety as a whole or for specific vigilances share the same information types but are not interoperable. An international initiative tries to develop an integrated information model for patient safety and vigilance reporting to support a global approach of heath care quality.

  7. The Patient Safety and Clinical Pharmacy Collaborative: improving medication use systems for the underserved.

    PubMed

    Wallack, Madeline Carpinelli; Loafman, Mark; Sorensen, Todd D

    2012-08-01

    The Patient Safety and Clinical Pharmacy Services Collaborative (PSPC) is demonstrating improvements in the quality of care delivered by safety-net organizations through integration of clinical pharmacy services. This article describes how the PSPC is leading meaningful change in the arena of medication use in management of chronic disease.

  8. Patient Safety Culture and the Association with Safe Resident Care in Nursing Homes

    ERIC Educational Resources Information Center

    Thomas, Kali S.; Hyer, Kathryn; Castle, Nicholas G.; Branch, Laurence G.; Andel, Ross; Weech-Maldonado, Robert

    2012-01-01

    Purpose of the study: Studies have shown that patient safety culture (PSC) is poorly developed in nursing homes (NHs), and, therefore, residents of NHs may be at risk of harm. Using Donabedian's Structure-Process-Outcome (SPO) model, we examined the relationships among top management's ratings of NH PSC, a process of care, and safety outcomes.…

  9. Self-reported patient safety competence among new graduates in medicine, nursing and pharmacy

    PubMed Central

    Ginsburg, Liane R; Tregunno, Deborah; Norton, Peter G

    2013-01-01

    Background As efforts to address patient safety (PS) in health professional (HP) education increase, it is important to understand new HPs’ perspectives on their own PS competence at entry to practice. This study examines the self-reported PS competence of newly registered nurses, pharmacists and physicians. Methods A cross-sectional survey of 4496 new graduates in medicine (1779), nursing (2196) and pharmacy (521) using the HP Education in PS Survey (H-PEPSS). The H-PEPSS measures HPs’ self-reported PS competence on six socio-cultural dimensions of PS, including culture, teamwork, communication, managing risk, responding to risk and understanding human factors. The H-PEPSS asks about confidence in PS learning in classroom and clinical settings. Results All HP groups reported feeling more confident in the dimension of PS learning related to effective communication with patients and other providers. Greater confidence in PS learning was reported for learning experiences in the clinical setting compared with the class setting with one exception—nurses’ confidence in learning about working in teams with other HPs deteriorated as they moved from thinking about learning in the classroom setting to thinking about learning in the clinical setting. Conclusions Large-scale efforts are required to more deeply and consistently embed PS learning into HP education. However, efforts to embed PS learning in HP education seem to be hampered by deficiencies that persist in the culture of the clinical training environments in which we educate and acculturate new HPs. PMID:23178859

  10. DICOM index tracker enterprise: advanced system for enterprise-wide quality assurance and patient safety monitoring

    NASA Astrophysics Data System (ADS)

    Zhang, Min; Pavlicek, William; Panda, Anshuman; Langer, Steve G.; Morin, Richard; Fetterly, Kenneth A.; Paden, Robert; Hanson, James; Wu, Lin-Wei; Wu, Teresa

    2015-03-01

    DICOM Index Tracker (DIT) is an integrated platform to harvest rich information available from Digital Imaging and Communications in Medicine (DICOM) to improve quality assurance in radiology practices. It is designed to capture and maintain longitudinal patient-specific exam indices of interests for all diagnostic and procedural uses of imaging modalities. Thus, it effectively serves as a quality assurance and patient safety monitoring tool. The foundation of DIT is an intelligent database system which stores the information accepted and parsed via a DICOM receiver and parser. The database system enables the basic dosimetry analysis. The success of DIT implementation at Mayo Clinic Arizona calls for the DIT deployment at the enterprise level which requires significant improvements. First, for geographically distributed multi-site implementation, the first bottleneck is the communication (network) delay; the second is the scalability of the DICOM parser to handle the large volume of exams from different sites. To address this issue, DICOM receiver and parser are separated and decentralized by site. To facilitate the enterprise wide Quality Assurance (QA), a notable challenge is the great diversities of manufacturers, modalities and software versions, as the solution DIT Enterprise provides the standardization tool for device naming, protocol naming, physician naming across sites. Thirdly, advanced analytic engines are implemented online which support the proactive QA in DIT Enterprise.

  11. The global counterfeit drug trade: patient safety and public health risks.

    PubMed

    Mackey, Tim K; Liang, Bryan A

    2011-11-01

    Counterfeit drugs are a global problem with significant and well-documented consequences for global health and patient safety, including drug resistance and patient deaths. This multibillion-dollar industry does not respect geopolitical borders, and threatens public health in both rich and resource-poor nations alike. The epidemiology of counterfeits is also wide in breadth and scope, including thousands of counterfeit incidents per year, encompassing all types of therapeutic classes, and employing a complex global supply chain network enabling this illegal activity. In addition, information technologies available through the Internet and sales via online pharmacies have allowed the criminal element to thrive in an unregulated environment of anonymity, deception, and lack of adequate enforcement. Though recent global enforcement efforts have led to arrests of online counterfeit sellers, such actions have not stemmed supplies from illegal online sellers or kept up with their creativity in illegally selling their products. To address this issue, we propose a global policy framework utilizing public-private partnership models with centralized surveillance reporting that would enable cooperation and coordination to combat this global health crisis.

  12. Low cost RFID real lightweight binding proof protocol for medication errors and patient safety.

    PubMed

    Yu, Yao-Chang; Hou, Ting-Wei; Chiang, Tzu-Chiang

    2012-04-01

    An Institute of Medicine Report stated there are 98,000 people annually who die due to medication related errors in the United States, and hospitals and other medical institutions are thus being pressed to use technologies to reduce such errors. One approach is to provide a suitable protocol that can cooperate with low cost RFID tags in order to identify patients. However, existing low cost RFID tags lack computational power and it is almost impossible to equip them with security functions, such as keyed hash function. To address this issue, a so a real lightweight binding proof protocol is proposed in this paper. The proposed protocol uses only logic gates (e.g. AND, XOR, ADD) to achieve the goal of proving that two tags exist in the field simultaneously, without the need for any complicated security algorithms. In addition, various scenarios are provider to explain the process of adopting this binding proof protocol with regard to guarding patient safety and preventing medication errors.

  13. Using swarm intelligence to boost the root cause analysis process and enhance patient safety.

    PubMed

    2016-03-01

    In an effort to strengthen patient safety, leadership at the University of Kentucky HealthCare (UKHC) decided to replace its traditional approach to root cause analysis (RCA) with a process based on swarm intelligence, a concept borrowed from other industries. Under this process, when a problem or error is identified, staff quickly hold a swarm--a meeting in which all those involved in the incident or problem quickly evaluate why the issue occurred and identify potential solutions for implementation. A pillar of the swarm concept is a mandate that there be no punishments or finger-pointing during the swarms. The idea is to encourage staff to be forthcoming to achieve effective solutions. Typically, swarms last for one hour and result in action plans designed to correct problems or deficiencies within a specific period of time. The ED was one of the first areas where UKHC applied swarms. For example, hospital administrators note that the approach has been used to address issues involving patient flow, triage protocols, assessments, overcrowding, and boarding. After seven years, incident reporting at UKHC has increased by 52%, and the health system has experienced a 37% decrease in the observed-to-expected mortality ratio.

  14. Feasibility of a Computer-Based Intervention Addressing Barriers to HIV Testing Among Young Patients Who Decline Tests at Triage.

    PubMed

    Aronson, Ian David; Cleland, Charles M; Perlman, David C; Rajan, Sonali; Sun, Wendy; Bania, Theodore C

    2016-09-01

    Young people face greatly increased human immunodeficiency virus (HIV) risk and high rates of undiagnosed HIV, yet are unlikely to test. Many also have limited or inconsistent access to health care, including HIV testing and prevention education, and prior research has documented that youth lack knowledge necessary to understand the HIV test process and to interpret test results. Computer-based interventions have been used to increase HIV test rates and knowledge among emergency department (ED) patients, including those who decline tests offered at triage. However, patients aged 18-24 years have been less likely to test, even after completing an intervention, compared to older patients in the same ED setting. The current pilot study sought to examine the feasibility and acceptability of a new tablet-based video intervention designed to address established barriers to testing among ED patients aged 18-24 years. In particular, we examined whether young ED patients would: agree to receive the intervention; complete it quickly enough to avoid disrupting clinical workflows; accept HIV tests offered by the intervention; demonstrate increased postintervention knowledge; and report they found the intervention acceptable. Over 4 weeks, we recruited 100 patients aged 18-24 in a high-volume urban ED; all of them declined HIV tests offered at triage. Almost all (98%) completed the intervention (mean time <9 mins), 30% accepted HIV tests offered by the tablets. Knowledge was significantly higher after than before the intervention (t = -6.67, p < .001) and patients reported generally high acceptability. Additional research appears warranted to increase postintervention HIV testing.

  15. Whole-patient measure of safety: using administrative data to assess the probability of highly undesirable events during hospitalization.

    PubMed

    Perla, Rocco J; Hohmann, Samuel F; Annis, Karen

    2013-01-01

    Hospitals often have limited ability to obtain primary clinical data from electronic health records to use in assessing quality and safety. We outline a new model that uses administrative data to gauge the safety of care at the hospital level. The model is based on a set of highly undesirable events (HUEs) defined using administrative data and can be customized to address the priorities and needs of different users. Patients with HUEs were identified using discharge abstracts from July 1, 2008 through June 30, 2010. Diagnoses were classified as HUEs based on the associated present-on-admission status. The 2-year study population comprised more than 6.5 million discharges from 161 hospitals. The proportion of hospitalizations including at least one HUE during the 24-month study period varied greatly among hospitals, with a mean of 7.74% (SD 2.3%) and a range of 13.32% (max, 15.31%; min, 1.99%). The whole-patient measure of safety provides a global measure to use in assessing hospitals with the patient's entire care experience in mind. As administrative and clinical datasets become more consistent, it becomes possible to use administrative data to compare the rates of HUEs across organizations and to identify opportunities for improvement.

  16. Unknown Safety and Efficacy of Smartphone Bolus Calculator Apps Puts Patients at Risk for Severe Adverse Outcomes.

    PubMed

    Hirsch, Irl B; Parkin, Christopher G

    2016-07-01

    Manual calculation of bolus insulin dosages can be challenging for individuals treated with multiple daily insulin injections (MDI) therapy. Automated bolus calculator capability has recently been made available via enhanced blood glucose meters and smartphone apps. Use of this technology has been shown to improve glycemic control and reduce glycemic variability without changing hypoglycemia; however, the clinical utility of app-based bolus calculators has not been demonstrated. Moreover, recent evidence challenges the safety and efficacy of these smartphone apps. Although the ability to automatically calculate bolus insulin dosages addresses a critical need of MDI-treated individuals, this technology raises concerns about efficacy of treatment and the protection of patient safety. This article discusses key issues and considerations associated with automated bolus calculator use.

  17. Allergic reaction to a red plastic allergy alert patient identification bracelet: implications for surgical patient safety.

    PubMed

    Colbert, Serryth; Williams, John V; Mackenzie, Neil; Brennan, Peter A

    2013-01-01

    We present a case of allergy to a hospital thermally-printed red plastic allergy alert bracelet in a 48 year old lady admitted to the day surgery unit. Two hours postoperatively, an intensely itchy area of erythema and oedema was seen extending from her left wrist distally to the fingers. The bracelet was removed and the rash resolved overnight without further complication. A diagnosis of contact dermatitis was made, secondary to exposure to an agent within the bracelet. We discuss the safety implications for surgical patients unable to wear an identification bracelet and the steps that may be taken to minimise the risk of harm from misidentification. We believe this to be the first documented case of an allergy to a patient identification bracelet in the medical literature.

  18. Teach-Back for quality education and patient safety.

    PubMed

    Tamura-Lis, Winifred

    2013-01-01

    Effective clinician-patient communication, a clear understanding of patient literacy, and use of the Teach-Back Method are useful tools in helping patients to better understand their own medical conditions. Educated patients are able to manage their medications, fully participate in their treatments, and follow protocols to achieve the goal of safe quality care. The end result is win-win: positive patient outcomes and increased patient satisfaction.

  19. Time to accelerate integration of human factors and ergonomics in patient safety.

    PubMed

    Gurses, Ayse P; Ozok, A Ant; Pronovost, Peter J

    2012-04-01

    Progress toward improving patient safety has been slow despite engagement of the health care community in improvement efforts. A potential reason for this sluggish pace is the inadequate integration of human factors and ergonomics principles and methods in these efforts. Patient safety problems are complex and rarely caused by one factor or component of a work system. Thus, health care would benefit from human factors and ergonomics evaluations to systematically identify the problems, prioritize the right ones, and develop effective and practical solutions. This paper gives an overview of the discipline of human factors and ergonomics and describes its role in improving patient safety. We provide examples of how human factors and ergonomics principles and methods have improved both care processes and patient outcomes. We provide five major recommendations to better integrate human factors and ergonomics in patient safety improvement efforts: build capacity among health care workers to understand human factors and ergonomics, create market forces that demand the integration of human factors and ergonomics design principles into medical technologies, increase the number of human factors and ergonomic practitioners in health care organizations, expand investments in improvement efforts informed by human factors and ergonomics, and support interdisciplinary research to improve patient safety. In conclusion, human factors and ergonomics must play a more prominent role in health care if we want to increase the pace in improving patient safety.

  20. Hospital nurses' working conditions in relation to motivation and patient safety.

    PubMed

    Toode, Kristi; Routasalo, Pirkko; Helminen, Mika; Suominen, Tarja

    2015-03-01

    There is a lack of empirical knowledge about nurses' perceptions of their workplace characteristics and conditions, such as level of autonomy and decision authority, work climate, teamwork, skill exploitation and learning opportunities, and their work motivation in relation to practice outputs such as patient safety. Such knowledge is needed particularly in countries, such as Estonia, where hospital systems for preventing errors and improving patient safety are in the early stages of development. This article reports the findings from a cross-sectional survey of hospital nurses in Estonia that was aimed at determining their perceptions of workplace characteristics, working conditions, work motivation and patient safety, and at exploring the relationship between these. Results suggest that perceptions of personal control over their work can affect nurses' motivation, and that perceptions of work satisfaction might be relevant to patient safety improvement work.

  1. Interruptions of nurses' activities and patient safety: an integrative literature review1

    PubMed Central

    Monteiro, Cintia; Avelar, Ariane Ferreira Machado; Pedreira, Mavilde da Luz Gonçalves

    2015-01-01

    OBJECTIVES: to identify characteristics related to the interruption of nurses in professional practice, as well as to assess the implications of interruptions for patient safety. METHOD: integrative literature review. The following databases were searched: Pubmed/Medline, LILACS, SciELO and Cochrane Library, using the descriptors interruptions and patient safety. An initial date was not established, but the final date was December 31, 2013. A total of 29 papers met the inclusion criteria. RESULTS: all the papers included describe interruptions as a harmful factor for patient safety. Data analysis revealed three relevant categories: characteristics of interruptions, implications for patient safety, and interventions to minimize interruptions. CONCLUSION: interruptions favor the occurrence of errors in the health field. Therefore, there is a need for further studies to understand such a phenomenon and its effects on clinical practice. PMID:25806646

  2. 2011 John M. Eisenberg Patient Safety and Quality Awards. Individual Achievement. Interview by Eric J. Thomas.

    PubMed

    Shine, Kenneth

    2012-07-01

    Dr. Shine, who, as president, led the Institute of Medicine's focus on quality and patient safety, describes initiatives at the University of Texas System, including quality improvement training, systems engineering, assessment of projects' economic impact, and dissemination of good practices.

  3. 75 FR 16140 - Common Formats for Patient Safety Data Collection and Event Reporting

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-03-31

    ... Collection and Event Reporting AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice... voluntarily collect and submit standardized information regarding patient safety events. The purpose of this... updated event descriptions, reports, data elements, and technical specifications for software...

  4. Quality Improvement Initiative Reduces Serious Safety Events in Pediatric Hospital Patients

    MedlinePlus

    ... Annual Conferences Newsletter AHRQ News Now Search News & Events Topics Search ahrq.gov About About AHRQ Profile ... May 2013 Quality improvement initiative reduces serious safety events in pediatric hospital patients Previous Page Next Page ...

  5. Patient Safety: Ten Things You Can Do to Be a Safe Patient

    MedlinePlus

    ... Emergency Preparedness & Response Environmental Health Healthy Living Injury, Violence & Safety Life Stages & Populations Travelers' Health Workplace Safety & Health Features Media Sign up for Features Get Email Updates To ...

  6. Suicide under crisis resolution home treatment – a key setting for patient safety

    PubMed Central

    Hunt, Isabelle M.; Appleby, Louis; Kapur, Nav

    2016-01-01

    Recent years have seen a substantial increase in the use of crisis resolution home treatment (CRHT) teams as an alternative to psychiatric in-patient admission. We discuss the functions of these services and their effectiveness. Our research suggests high rates of suicide in patients under CRHT. Specific strategies need to be developed to improve patient safety in this setting. PMID:27512582

  7. Patient Safety Incidents in Home Hospice Care: The Experiences of Hospice Interdisciplinary Team Members

    PubMed Central

    Regan, Saundra; Elder, Nancy C.; Gerrety, Erica

    2014-01-01

    Abstract Background: Hospice provides a full range of services for patients near the end of life, often in the patient's own home. There are no published studies that describe patient safety incidents in home hospice care. Objective: The study objective was to explore the types and characteristics of patient safety incidents in home hospice care from the experiences of hospice interdisciplinary team members. Methods: The study design is qualitative and descriptive. From a convenience sample of 17 hospices in 13 states we identified 62 participants including hospice nurses, physicians, social workers, chaplains, and home health aides. We interviewed a separate sample of 19 experienced hospice leaders to assess the credibility of primary results. Semistructured telephone interviews were recorded and transcribed. Four researchers used an editing technique to identify common themes from the interviews. Results: Major themes suggested a definition of patient safety in home hospice that includes concern for unnecessary harm to family caregivers or unnecessary disruption of the natural dying process. The most commonly described categories of patient harm were injuries from falls and inadequate control of symptoms. The most commonly cited contributing factors were related to patients, family caregivers, or the home setting. Few participants recalled incidents or harm related to medical errors by hospice team members. Conclusions: This is the first study to describe patient safety incidents from the experiences of hospice interdisciplinary team members. Compared with patient safety studies from other health care settings, participants recalled few incidents related to errors in evaluation, treatment, or communication by the hospice team. PMID:24576084

  8. [Design, implementation and evaluation of a management model of patient safety in hospitals in Catalonia, Spain].

    PubMed

    Saura, Rosa Maria; Moreno, Pilar; Vallejo, Paula; Oliva, Glòria; Alava, Fernando; Esquerra, Miquel; Davins, Josep; Vallès, Roser; Bañeres, Joaquim

    2014-07-01

    Since its inception in 2006, the Alliance for Patient Safety in Catalonia has played a major role in promoting and shaping a series of projects related to the strategy of the Ministry of Health, Social Services and Equality, for improving patient safety. One such project was the creation of functional units or committees of safety in hospitals in order to facilitate the management of patient safety. The strategy has been implemented in hospitals in Catalonia which were selected based on criteria of representativeness. The intervention was based on two lines of action, one to develop the model framework and the other for its development. Firstly the strategy for safety management based on EFQM (European Foundation for Quality Management) was defined with the development of standards, targets and indicators to implement security while the second part involved the introduction of tools, methodologies and knowledge to the management support of patient safety and risk prevention. The project was developed in four hospital areas considered higher risk, each assuming six goals for safety management. Some of these targets such as the security control panel or system of adverse event reporting were shared. 23 hospitals joined the project in Catalonia. Despite the different situations in each centre, high compliance was achieved in the development of the objectives. In each of the participating areas the security control panel was developed. Stable structures for safety management were established or strengthened. Training in patient safety played and important role, 1415 professionals participated. Through these kind of projects not only have been introduced programs of proven effectiveness in reducing risks, but they also provide to the facilities a work system that allows autonomy in diagnosis and analysis of the different risk situations or centre specific safety issues.

  9. Improving patient safety in a UK dental hospital: long-term use of clinical audit.

    PubMed

    Ashley, M P; Pemberton, M N; Saksena, A; Shaw, A; Dickson, S

    2014-10-01

    The improvement of patient safety has been a long-term aim of healthcare organisations and following recent negative events within the UK, the focus on safety has rightly increased. For over twenty years, clinical audit has been the tool most frequently used to measure safety-related aspects of healthcare and when done so correctly, can lead to sustained improvements. This paper explains how clinical audit is used as a safety improvement tool in an English dental hospital and gives several examples of projects that have resulted in long-term improvements in secondary dental care.

  10. Patient safety through RFID: vulnerabilities in recently proposed grouping protocols.

    PubMed

    Wickboldt, Anne-Katrin; Piramuthu, Selwyn

    2012-04-01

    As RFID-tagged systems become ubiquitous, acceptance of this technology by the general public necessitates addressing related security/privacy issues. The past eight years have seen an increasing number of publications in this direction, specifically using cryptographic approaches. Recently, the Journal of Medical Systems published two papers addressing security/privacy issues through cryptographic protocols. We consider the proposed protocols and identify some existing vulnerabilities.

  11. Workplace empowerment and magnet hospital characteristics as predictors of patient safety climate.

    PubMed

    Armstrong, Kevin; Laschinger, Heather; Wong, Carol

    2009-01-01

    This study tested a theoretical model derived from Kanter's theory of workplace empowerment by surveying a random sample of 300 registered nurses employed in acute care hospitals across the Canadian province of Ontario. The results of this study effectively replicated the findings of a previous exploratory study. Specific nursing practice environment characteristics that positively influence the climate of patient safety were identified. This study provides nurse leaders with ideas for improving the patient safety climate by improving the quality of nurses' work environments.

  12. Safety of Rural Nursing Home-to-Emergency Department Transfers: Improving Communication and Patient Information Sharing Across Settings.

    PubMed

    Tupper, Judith B; Gray, Carolyn E; Pearson, Karen B; Coburn, Andrew F

    2015-01-01

    The "siloed" approach to healthcare delivery contributes to communication challenges and to potential patient harm when patients transfer between settings. This article reports on the evaluation of a demonstration in 10 rural communities to improve the safety of nursing facility (NF) transfers to hospital emergency departments by forming interprofessional teams of hospital, emergency medical service, and NF staff to develop and implement tools and protocols for standardizing critical interfacility communication pathways and information sharing. We worked with each of the 10 teams to document current communication processes and information sharing tools and to design, implement, and evaluate strategies/tools to increase effective communication and sharing of patient information across settings. A mixed methods approach was used to evaluate changes from baseline in documentation of patient information shared across settings during the transfer process. Study findings showed significant improvement in key areas across the three settings, including infection status and baseline mental functioning. Improvement strategies and performance varied across settings; however, accurate and consistent information sharing of advance directives and medication lists remains a challenge. Study results demonstrate that with neutral facilitation and technical support, collaborative interfacility teams can assess and effectively address communication and information sharing problems that threaten patient safety.

  13. Food safety for the solid organ transplant patient: preventing foodborne illness while on chronic immunosuppressive drugs.

    PubMed

    Obayashi, Patricia A C

    2012-12-01

    Issues regarding food safety are seen increasingly in the news; outbreaks of foodborne illness have been associated with public health concerns ranging from mild illness to death. For the solid organ transplant patient, immunosuppressive and antibacterial drugs, which maintain transplant organ function, can expose the transplant patient to increased risk of foodborne illness from bacteria, viruses, fungi, and parasites. This review article describes the clinical consequences, sources of foodborne illness, and food safety practices needed to minimize risks to the solid organ transplant patient who must take lifelong immunosuppressive drugs. All members of the transplant team share responsibility for education of the solid organ transplant patient in preventing infections. The registered dietitian, as part of the transplant team, is the recognized expert in providing food safety education in the context of medical nutrition therapy to solid organ transplant patients, the patients' caregivers, and other healthcare providers.

  14. Expediting Clinician Adoption of Safety Practices: The UCSF Venous Access Patient Safety Interdisciplinary Education Project

    DTIC Science & Technology

    2005-01-01

    3) the interplay between theoretical and applied knowledge in VAD clinical applications, and (4) learning styles or strategies specific to each...safety, such as VAD removal, also were added to appeal to differences in the learning styles and learning preferences of the target groups. Advances in...dilemmas with clinical practitioners was ongoing throughout the developmental process. Literature reviews related to learning styles and strategies

  15. 21 CFR 312.88 - Safeguards for patient safety.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... within parts 50, 56, 312, 314, and 600 of this chapter designed to ensure the safety of clinical testing... (part 56 of this chapter). These safeguards further include the review of animal studies prior to initial human testing (§ 312.23), and the monitoring of adverse drug experiences through the...

  16. The Impact of Market Orientation on Patient Safety Climate Among Hospital Nurses.

    PubMed

    Weng, Rhay-Hung; Chen, Jung-Chien; Pong, Li-Jung; Chen, Li-Mei; Lin, Tzu-Chi

    2016-03-01

    Improving market orientation and patient safety have become the key concerns of nursing management. For nurses, establishing a patient safety climate is the key to enhancing nursing quality. This study explores how market orientation affects the climate of patient safety among hospital nurses. We proposed adopting a cross-sectional research design and using questionnaires to collect responses from nurses working in two Taiwanese hospitals. Three-hundred and forty-three valid samples were obtained. Multiple regression and path analyses were conducted to test the study. Market orientation was defined as the combination of customer orientation, competitor orientation, and interfunctional coordination. Customer orientation directly affects the climate of patient safety. Although the findings only supported Hypothesis 1, competitor orientation and interfunctional coordination positively affected the patient safety climate through the mediating effects of hospital support for staff. Health care managers could encourage nurses to adopt customer-oriented perspectives to enhance their nursing care. In addition, to enhance competitor orientation, interfunctional coordination, and the patient safety climate, hospital managers could strengthen their support for staff members.

  17. Measuring cross-cultural patient safety: identifying barriers and developing performance indicators.

    PubMed

    Walker, Roger; St Pierre-Hansen, Natalie; Cromarty, Helen; Kelly, Len; Minty, Bryanne

    2010-01-01

    Medical errors and cultural errors threaten patient safety. We know that access to care, quality of care and clinical safety are all impacted by cultural issues. Numerous approaches to describing cultural barriers to patient safety have been developed, but these taxonomies do not provide a useful set of tools for defining the nature of the problem and consequently do not establish a sound base for problem solving. The Sioux Lookout Meno Ya Win Health Centre has implemented a cross-cultural patient safety (CCPS) model (Walker 2009). We developed an analytical CCPS framework within the organization, and in this article, we detail the validation process for our framework by way of a literature review and surveys of local and international healthcare professionals. We reinforce the position that while cultural competency may be defined by the service provider, cultural safety is defined by the client. In addition, we document the difficulties surrounding the measurement of cultural competence in terms of patient outcomes, which is an underdeveloped dimension of the field of patient safety. We continue to explore the correlation between organizational performance and measurable patient outcomes.

  18. Elective surgical patients' narratives of hospitalization: the co-construction of safety.

    PubMed

    Doherty, Carole; Saunders, Mark N K

    2013-12-01

    This research explores how elective surgical patients make sense of their hospitalization experiences. We explore sensemaking using longitudinal narrative interviews (n=72) with 38 patients undergoing elective surgical procedures between June 2010 and February 2011. We consider patients' narratives, the stories they tell of their prior expectations, and subsequent post-surgery experiences of their care in a United Kingdom (UK) hospital. An emergent pre-surgery theme is that of a paradoxical position in which they choose to make themselves vulnerable by agreeing to surgery to enhance their health, this necessitating trust of clinicians (doctors and nurses). To make sense of their situation, patients draw on technical (doctors' expert knowledge and skills), bureaucratic (National Health Service as a revered institution) and ideological (hospitals as places of safety), discourses. Post-operatively, themes of 'chaos' and 'suffering' emerge from the narratives of patients whose pre-surgery expectations (and trust) have been violated. Their stories tell of unmet expectations and of inability to make shared sense of experiences with clinicians who are responsible for their care. We add to knowledge of how patients play a critical part in the co-construction of safety by demonstrating how patient-clinician intersubjectivity contributes to the type of harm that patients describe. Our results suggest that approaches to enhancing patients' safety will be limited if they fail to reflect patients' involvement in the negotiated process of healthcare. We also provide further evidence of the contribution narrative inquiry can make to patient safety.

  19. Safety and efficacy of adalimumab treatment in Japanese patients with psoriasis: Results of SALSA study.

    PubMed

    Asahina, Akihiko; Torii, Hideshi; Ohtsuki, Mamitaro; Tokimoto, Toshimitsu; Hase, Hidenori; Tsuchiya, Tsuyoshi; Shinmura, Yasuhiko; Reyes Servin, Ofelia; Nakagawa, Hidemi

    2016-11-01

    The safety and efficacy of adalimumab were evaluated over 24 weeks in Japanese patients with psoriasis in routine clinical practice. In this multicenter, observational, open-label, postmarketing study, primary efficacy measures included the Psoriasis Area and Severity Index (PASI) and the Dermatology Life Quality Index (DLQI) in all patients with psoriasis. In patients with psoriatic arthritis (PsA), the 28-joint Disease Activity Score (DAS28) and the visual analog scale (VAS) pain were also evaluated. Safety was assessed based on the frequency of adverse drug reactions (ADR). Among patients with psoriasis evaluated for efficacy (n = 604), significant improvements from baseline were observed in mean PASI and DLQI scores at weeks 16 and 24 (all P < 0.0001). Furthermore, in psoriasis patients without PsA, the PASI 75/90 response rates were 55.9%/28.4% at week 16 (n = 306) and 65.6%/43.3% at week 24 (n = 270), respectively. In patients with PsA evaluable for effectiveness, significant improvements from baseline were observed in PASI, DAS28 erythrocyte sedimentation rate, DAS28 C-reactive protein and VAS pain at weeks 16 and 24 (all P < 0.0001). ADR and serious ADR were reported by 26.1% and 3.3%, respectively, of 731 safety evaluable patients with psoriasis; no unexpected safety findings were noted. The safety profile and effectiveness of adalimumab for the treatment of psoriasis in a routine clinical setting were as expected in Japanese patients.

  20. Patient safety priorities in mental healthcare in Switzerland: a modified Delphi study

    PubMed Central

    Mascherek, Anna C

    2016-01-01

    Objective Identifying patient safety priorities in mental healthcare is an emerging issue. A variety of aspects of patient safety in medical care apply for patient safety in mental care as well. However, specific aspects may be different as a consequence of special characteristics of patients, setting and treatment. The aim of the present study was to combine knowledge from the field and research and bundle existing initiatives and projects to define patient safety priorities in mental healthcare in Switzerland. The present study draws on national expert panels, namely, round-table discussion and modified Delphi consensus method. Design As preparation for the modified Delphi questionnaire, two round-table discussions and one semistructured questionnaire were conducted. Preparative work was conducted between May 2015 and October 2015. The modified Delphi was conducted to gauge experts' opinion on priorities in patient safety in mental healthcare in Switzerland. In two independent rating rounds, experts made private ratings. The modified Delphi was conducted in winter 2015. Results Nine topics were defined along the treatment pathway: diagnostic errors, non-drug treatment errors, medication errors, errors related to coercive measures, errors related to aggression management against self and others, errors in treatment of suicidal patients, communication errors, errors at interfaces of care and structural errors. Conclusions Patient safety is considered as an important topic of quality in mental healthcare among experts, but it has been seriously neglected up until now. Activities in research and in practice are needed. Structural errors and diagnostics were given highest priority. From the topics identified, some are overlapping with important aspects of patient safety in medical care; however, some core aspects are unique. PMID:27496233

  1. A Risk Analysis Methodology to Address Human and Organizational Factors in Offshore Drilling Safety: With an Emphasis on Negative Pressure Test

    NASA Astrophysics Data System (ADS)

    Tabibzadeh, Maryam

    According to the final Presidential National Commission report on the BP Deepwater Horizon (DWH) blowout, there is need to "integrate more sophisticated risk assessment and risk management practices" in the oil industry. Reviewing the literature of the offshore drilling industry indicates that most of the developed risk analysis methodologies do not fully and more importantly, systematically address the contribution of Human and Organizational Factors (HOFs) in accident causation. This is while results of a comprehensive study, from 1988 to 2005, of more than 600 well-documented major failures in offshore structures show that approximately 80% of those failures were due to HOFs. In addition, lack of safety culture, as an issue related to HOFs, have been identified as a common contributing cause of many accidents in this industry. This dissertation introduces an integrated risk analysis methodology to systematically assess the critical role of human and organizational factors in offshore drilling safety. The proposed methodology in this research focuses on a specific procedure called Negative Pressure Test (NPT), as the primary method to ascertain well integrity during offshore drilling, and analyzes the contributing causes of misinterpreting such a critical test. In addition, the case study of the BP Deepwater Horizon accident and their conducted NPT is discussed. The risk analysis methodology in this dissertation consists of three different approaches and their integration constitutes the big picture of my whole methodology. The first approach is the comparative analysis of a "standard" NPT, which is proposed by the author, with the test conducted by the DWH crew. This analysis contributes to identifying the involved discrepancies between the two test procedures. The second approach is a conceptual risk assessment framework to analyze the causal factors of the identified mismatches in the previous step, as the main contributors of negative pressure test

  2. Professional conceptualisation and accomplishment of patient safety in mental healthcare: an ethnographic approach

    PubMed Central

    2011-01-01

    Background This study seeks to broaden current understandings of what patient safety means in mental healthcare and how it is accomplished. We propose a qualitative observational study of how safety is produced or not produced in the complex context of everyday professional mental health practice. Such an approach intentionally contrasts with much patient safety research which assumes that safety is achieved and improved through top-down policy directives. We seek instead to understand and articulate the connections and dynamic interactions between people, materials, and organisational, legal, moral, professional and historical safety imperatives as they come together at particular times and places to perform safe or unsafe practice. As such we advocate an understanding of patient safety 'from the ground up'. Methods/Design The proposed project employs a six-phase data collection framework in two mental health settings: an inpatient unit and a community team. The first four phases comprise multiple modes of focussed, unobtrusive observation of professionals at work, to enable us to trace the conceptualisation and enactment of safety as revealed in dialogue and narrative, use of artefacts and space, bodily activity and patterns of movement, and in the accomplishment of specific work tasks. An interview phase and a social network analysis phase will subsequently be conducted to offer comparative perspectives on the observational data. This multi-modal and holistic approach to studying patient safety will complement existing research, which is dominated by instrumentalist approaches to discovering factors contributing to error, or developing interventions to prevent or manage adverse events. Discussion This ethnographic research framework, informed by the principles of practice theories and in particular actor-network ideas, provides a tool to aid the understanding of patient safety in mental healthcare. The approach is novel in that it seeks to articulate an 'anatomy

  3. [Endorsement of risk management and patient safety by certification of conformity in health care quality assessment].

    PubMed

    Waßmuth, Ralf

    2015-01-01

    Certification of conformity in health care should provide assurance of compliance with quality standards. This also includes risk management and patient safety. Based on a comprehensive definition of quality, beneficial effects on the management of risks and the enhancement of patient safety can be expected from certification of conformity. While these effects have strong face validity, they are currently not sufficiently supported by evidence from health care research. Whether this relates to a lack of evidence or a lack of investigation remains open. Advancing safety culture and "climate", as well as learning from adverse events rely in part on quality management and are at least in part reflected in the certification of healthcare quality. However, again, evidence of the effectiveness of such measures is limited. Moreover, additional factors related to personality, attitude and proactive action of healthcare professionals are crucial factors in advancing risk management and patient safety which are currently not adequately reflected in certification of conformity programs.

  4. The Value of Human Factors to Medication and Patient Safety in the ICU

    PubMed Central

    Scanlon, Matthew C.; Karsh, Ben-Tzion

    2010-01-01

    Conventional wisdom suggests that the “human factor” in critical care environments is reason for inadequate medication and patient safety. Human factors (or human factors engineering (HFE)) is the science and practice of improving human performance. Using decades of HFE research, this paper evaluates a range of common beliefs about patient safety through a human factors lens. This evaluation demonstrates that HFE provides a framework for understanding safety failures in critical care settings, offers insights in to how to improve medication and patient safety, and reminds us that the “human factor” in critical care units is what allows these time pressured, information intense, mentally challenging, interruption-laden, and life-or-death environments to function so safely so much of the time. PMID:20502180

  5. To the Point: Integrating Patient Safety Education Into the Obstetrics and Gynecology Undergraduate Curriculum.

    PubMed

    Abbott, Jodi F; Pradhan, Archana; Buery-Joyner, Samantha; Casey, Petra M; Chuang, Alice; Dugoff, Lorraine; Dalrymple, John L; Forstein, David A; Hampton, Brittany S; Hueppchen, Nancy A; Kaczmarczyk, Joseph M; Katz, Nadine T; Nuthalapaty, Francis S; Page-Ramsey, Sarah; Wolf, Abigail; Cullimore, Amie J

    2016-07-26

    This article is part of the To the Point Series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee. Principles and education in patient safety have been well integrated into academic obstetrics and gynecology practices, although progress in safety profiles has been frustratingly slow. Medical students have not been included in the majority of these ambulatory practice or hospital-based initiatives. Both the Association of American Medical Colleges and Accreditation Council for Graduate Medical Education have recommended incorporating students into safe practices. The Accreditation Council for Graduate Medical Education milestone 1 for entering interns includes competencies in patient safety. We present data and initiatives in patient safety, which have been successfully used in undergraduate and graduate medical education. In addition, this article demonstrates how using student feedback to assess sentinel events can enhance safe practice and quality improvement programs. Resources and implementation tools will be discussed to provide a template for incorporation into educational programs and institutions. Medical student involvement in the culture of safety is necessary for the delivery of both high-quality education and high-quality patient care. It is essential to incorporate students into the ongoing development of patient safety curricula in obstetrics and gynecology.

  6. A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and patient safety.

    PubMed

    Xie, Anping; Carayon, Pascale

    2015-01-01

    Healthcare systems need to be redesigned to provide care that is safe, effective and efficient, and meets the multiple needs of patients. This systematic review examines how human factors and ergonomics (HFE) is applied to redesign healthcare work systems and processes and improve quality and safety of care. We identified 12 projects representing 23 studies and addressing different physical, cognitive and organisational HFE issues in a variety of healthcare systems and care settings. Some evidence exists for the effectiveness of HFE-based healthcare system redesign in improving process and outcome measures of quality and safety of care. We assessed risk of bias in 16 studies reporting the impact of HFE-based healthcare system redesign and found varying quality across studies. Future research should further assess the impact of HFE on quality and safety of care, and clearly define the mechanisms by which HFE-based system redesign can improve quality and safety of care.

  7. Surgical innovation-enhanced quality and the processes that assure patient/provider safety: A surgical conundrum.

    PubMed

    Bruny, Jennifer; Ziegler, Moritz

    2015-12-01

    Innovation is a crucial part of surgical history that has led to enhancements in the quality of surgical care. This comprises both changes which are incremental and those which are frankly disruptive in nature. There are situations where innovation is absolutely required in order to achieve quality improvement or process improvement. Alternatively, there are innovations that do not necessarily arise from some need, but simply are a new idea that might be better. All change must assure a significant commitment to patient safety and beneficence. Innovation would ideally enhance patient care quality and disease outcomes, as well stimulate and facilitate further innovation. The tensions between innovative advancement and patient safety, risk and reward, and demonstrated effectiveness versus speculative added value have created a contemporary "surgical conundrum" that must be resolved by a delicate balance assuring optimal patient/provider outcomes. This article will explore this delicate balance and the rules that govern it. Recommendations are made to facilitate surgical innovation through clinical research. In addition, we propose options that investigators and institutions may use to address competing priorities.

  8. Exploring the Validity of Developing an Interdisciplinarity Score of a Patient's Needs: Care Coordination, Patient Complexity, and Patient Safety Indicators.

    PubMed

    Hodgson, Ashley; Etzkorn, Lacey; Everhart, Alexander; Nooney, Nicholas; Bestrashniy, Jessica

    Despite the Affordable Care Act's push to improve the coordination of care for patients with multiple chronic conditions, most measures of coordination quality focus on a specific moment in the care process (e.g., medication errors or transfer between facilities), rather than patient outcomes. One possible supplementary way of measuring the care coordination quality of a facility would be to identify the patients needing the most coordination, and to look at outcomes for that group. This paper lays the groundwork for a new measure of care coordination quality by outlining a conceptual framework that considers the interaction between a patient's interdisciplinarity, biological susceptibility, and procedural intensity. Interdisciplinarity captures the degree of specialized medical expertise needed for a patient's care and will be an important measure to estimate the number of specialists a patient might see. We then develop a preliminary measure of interdisciplinarity and run tests linking interdisciplinarity to medical mistakes, as defined by Agency for Healthcare Research and Quality's Patient Safety Indicators. Finally, we use our preliminary measure to verify that interdisciplinarity is likely to be statistically different from existing measures of comorbidity, like the Charlson score. Future research will need to build upon our findings by developing a more statistically validated measure of interdisciplinarity.

  9. Trends and Patterns in Reporting of Patient Safety Situations in Transplantation.

    PubMed

    Stewart, D E; Tlusty, S M; Taylor, K H; Brown, R S; Neil, H N; Klassen, D K; Davis, J A; Daly, T M; Camp, P C; Doyle, A M

    2015-12-01

    Analysis and dissemination of transplant patient safety data are essential to understanding key issues facing the transplant community and fostering a "culture of safety." The Organ Procurement and Transplantation Network's (OPTN) Operations and Safety Committee de-identified safety situations reported through several mechanisms, including the OPTN's online patient safety portal, through which the number of reported cases has risen sharply. From 2012 to 2013, 438 events were received through either the online portal or other reporting pathways, and about half were self-reports. Communication breakdowns (22.8%) and testing issues (16.0%) were the most common types. Events included preventable errors that led to organ discard as well as near misses. Among events reported by Organ Procurement Organization (OPOs), half came from just 10 of the 58 institutions, while half of events reported by transplant centers came from just 21 of 250 institutions. Thirteen (23%) OPOs and 155 (62%) transplant centers reported no events, suggesting substantial underreporting of safety-related errors to the national database. This is the first comprehensive, published report of the OPTN's safety efforts. Our goals are to raise awareness of safety data recently reported to the OPTN, encourage additional reporting, and spur systems improvements to mitigate future risk.

  10. A systematic review of Human Factors and Ergonomics (HFE)-based healthcare system redesign for quality of care and patient safety

    PubMed Central

    Xie, Anping; Carayon, Pascale

    2014-01-01

    Healthcare systems need to be redesigned to provide care that is safe, effective and efficient, and meets the multiple needs of patients. This systematic review examines how Human Factors and Ergonomics (HFE) is applied to redesign healthcare work systems and processes and improve quality and safety of care. We identified twelve projects representing 23 studies and addressing different physical, cognitive and organizational HFE issues in a variety of healthcare systems and care settings. Some evidence exists for the effectiveness of HFE-based healthcare system redesign in improving process and outcome measures of quality and safety of care. We assessed risk of bias in 16 studies reporting the impact of HFE-based healthcare system redesign and found varying quality across studies. Future research should further assess the impact of HFE on quality and safety of care, and clearly define the mechanisms by which HFE-based system redesign can improve quality and safety of care. Practitioner Summary Existing evidence shows that HFE-based healthcare system redesign has the potential to improve quality of care and patient safety. Healthcare organizations need to recognize the importance of HFE-based healthcare system redesign to quality of care and patient safety, and invest resources to integrate HFE in healthcare improvement activities. PMID:25323570

  11. Relationship between high-fidelity simulation and patient safety in prelicensure nursing education: a comprehensive review.

    PubMed

    Blum, Cynthia Ann; Parcells, Dax Andrew

    2012-08-01

    Advances in nursing simulation technology raise the question "Are educators feeling pressure to accommodate the learning styles of the techno-age studentry?" This integrative review evaluates the current quantitative evidence from preintervention-postintervention and control-experimental research studies related to the use of simulation in prelicensure nursing education directed at enhancing safety in nursing practice. A thorough review of the available literature using truncated search terms in several databases yielded 258 scholarly, peer-reviewed articles, of which 18 articles directly addressed the posed research question related to simulation and safety. Replete with student reports of simulation as an enjoyable learning activity, the literature does not yet support simulation over other approaches to the teaching-learning of safety competencies in nursing. Therefore, nurse educators must continue to select the most appropriate methods based on the specific course, student, or program type, with concentrated focus on competency-based safety education in nursing.

  12. Key Performance Outcomes of Patient Safety Curricula: Root Cause Analysis, Failure Mode and Effects Analysis, and Structured Communications Skills

    PubMed Central

    2011-01-01

    As colleges and schools of pharmacy develop core courses related to patient safety, course-level outcomes will need to include both knowledge and performance measures. Three key performance outcomes for patient safety coursework, measured at the course level, are the ability to perform root cause analyses and healthcare failure mode effects analyses, and the ability to generate effective safety communications using structured formats such as the Situation-Background-Assessment-Recommendation (SBAR) situational briefing model. Each of these skills is widely used in patient safety work and competence in their use is essential for a pharmacist's ability to contribute as a member of a patient safety team. PMID:22102754

  13. The evolving role of health educators in advancing patient safety: forging partnerships and leading change.

    PubMed

    Mercurio, Annette

    2007-04-01

    At least 1.5 million preventable injuries because of adverse drug events occur in the United States each year, according to an Institute of Medicine report. IOM and other organizations at the forefront of health care improvement emphasize that stronger partnerships between patients, their families, and health care providers are necessary to make health care safer. Health educators possess a skill set and an ethical framework that effectively equip them to advance patient and family-centered care and contribute in other significant ways to a safer health care system. Health educators in clinical settings are playing varied and significant roles in advancing patient safety. They are removing barriers to clear communication and forging partnerships between patients, their families, and staff. Health educators are leading patient safety culture change within their institutions and contributing to the shift from provider-centric to patient-centric systems. To expand their impact in improving patient safety, health educators in clinical settings are participating in public awareness campaigns. In seeking to enhance patient safety, health educators face a number of challenges. To successfully manage those, health educators must expand their knowledge, broaden connections, and engage patients and families in meaningful ways.

  14. Patient-Safety-Related Hospital Deaths in England: Thematic Analysis of Incidents Reported to a National Database, 2010–2012

    PubMed Central

    Donaldson, Liam J.; Panesar, Sukhmeet S.; Darzi, Ara

    2014-01-01

    Background Hospital mortality is increasingly being regarded as a key indicator of patient safety, yet methodologies for assessing mortality are frequently contested and seldom point directly to areas of risk and solutions. The aim of our study was to classify reports of deaths due to unsafe care into broad areas of systemic failure capable of being addressed by stronger policies, procedures, and practices. The deaths were reported to a patient safety incident reporting system after mandatory reporting of such incidents was introduced. Methods and Findings The UK National Health Service database was searched for incidents resulting in a reported death of an adult over the period of the study. The study population comprised 2,010 incidents involving patients aged 16 y and over in acute hospital settings. Each incident report was reviewed by two of the authors, and, by scrutinising the structured information together with the free text, a main reason for the harm was identified and recorded as one of 18 incident types. These incident types were then aggregated into six areas of apparent systemic failure: mismanagement of deterioration (35%), failure of prevention (26%), deficient checking and oversight (11%), dysfunctional patient flow (10%), equipment-related errors (6%), and other (12%). The most common incident types were failure to act on or recognise deterioration (23%), inpatient falls (10%), healthcare-associated infections (10%), unexpected per-operative death (6%), and poor or inadequate handover (5%). Analysis of these 2,010 fatal incidents reveals patterns of issues that point to actionable areas for improvement. Conclusions Our approach demonstrates the potential utility of patient safety incident reports in identifying areas of service failure and highlights opportunities for corrective action to save lives. Please see later in the article for the Editors' Summary PMID:24959751

  15. Students' Perceptions of Patient Safety during the Transition from Undergraduate to Postgraduate Training: An Activity Theory Analysis

    ERIC Educational Resources Information Center

    de Feijter, Jeantine M.; de Grave, Willem S.; Dornan, Tim; Koopmans, Richard P.; Scherpbier, Albert J. J. A.

    2011-01-01

    Evidence that medical error can cause harm to patients has raised the attention of the health care community towards patient safety and influenced how and what medical students learn about it. Patient safety is best taught when students are participating in clinical practice where they actually encounter patients at risk. This type of learning is…

  16. Patient Safety Events and Harms During Medical and Surgical Hospitalizations for Persons With Serious Mental Illness

    PubMed Central

    Daumit, Gail L.; McGinty, Emma E.; Pronovost, Peter; Dixon, Lisa B.; Guallar, Eliseo; Ford, Daniel E.; Cahoon, Elizabeth K.; Boonyasai, Romsai T.; Thompson, David

    2016-01-01

    Objective This study explored the risk of patient safety events and associated nonfatal physical harms and mortality in a cohort of persons with serious mental illness. This group experiences high rates of medical comorbidity and premature mortality and may be at high risk of adverse patient safety events. Methods Medical record review was conducted for medical-surgical hospitalizations occurring during 1994–2004 in a community-based cohort of Maryland adults with serious mental illness. Individuals were eligible if they died within 30 days of a medical-surgical hospitalization and if they also had at least one prior medical-surgical hospitalization within five years of death. All admissions took place at Maryland general hospitals. A case-crossover analysis examined the relationships among patient safety events, physical harms, and elevated likelihood of death within 30 days of hospitalization. Results A total of 790 hospitalizations among 253 adults were reviewed. The mean number of patient safety events per hospitalization was 5.8, and the rate of physical harms was 142 per 100 hospitalizations. The odds of physical harm were elevated in hospitalizations in which 22 of the 34 patient safety events occurred (p<.05), including medical events (odds ratio [OR]=1.5, 95% confidence interval [CI]=1.3–1.7) and procedure-related events (OR=1.6, CI=1.2–2.0). Adjusted odds of death within 30 days of hospitalization were elevated for individuals with any patient safety event, compared with those with no event (OR=3.7, CI=1.4–10.3). Conclusions Patient safety events were positively associated with physical harm and 30-day mortality in nonpsychiatric hospitalizations for persons with serious mental illness. PMID:27181736

  17. Navigating the information technology highway: computer solutions to reduce errors and enhance patient safety.

    PubMed

    Koshy, Ranie

    2005-10-01

    Standardized, seamless, integrated information technology in the health-care environment used with other industry tools can markedly decrease preventable errors or adverse events and increase patient safety. According to an Institute of Medicine (IOM) report released in 1999, preventable errors have caused between 44,000 and 98,000 deaths per year. Following the report, President Bill Clinton requested that the Agency of Healthcare Research and Quality, a government agency, look into the issue and fund, at the local or state level, processes that can reduce errors. Funding subsequently was made available for research that utilizes best practice tools in clinical practice to increase patient safety. The Joint Commission on Accreditation of Healthcare Organization has placed a great deal of emphasis on strategies to reduce patient identification errors. Fragmented systems tout the individual as well as enhanced safety applications. These applications, however, are related to prevention in specific conditions and in specific health-care settings. Systems are not integrated with common reference data and common terminology aggregated at a regional or national level to provide access to patient safety risks for timely interventions before errors and adverse events occur. Standardized integrated patient care information systems are not available either on a regional or on a national level. This article examines tangible options to increase patient safety through improved state-of-the-art tools that can be incorporated into the health-care system to prevent errors.

  18. Patient information on drug therapy. A problem of medical malpractice law: between product safety and user safety.

    PubMed

    Hart, Dieter

    2007-04-01

    Medicinal products are associated with risks as well as potential therapeutic benefits. This is reflected by the legal requirements for patient information on drug therapy which can be differentiated into general product information, regulated by pharmaceutical (i. e. product safety) law, and individual patient information on the treatment with the product, which is subject to medical malpractice law. The physician's duty to inform the patient comprises therapeutic information as well as information required for informed consent. Therapeutic information intends to empower the patient to comply with the requirements of treatment and to protect him/her against preventable danger and risk; it is part of the medical treatment, aimed at the individual patient and his/her personal situation. Information required for informed consent enables the patient to a self-determined decision on the treatment offered; it can be divided into information on the course of treatment and risk information. Product information and treatment information complement each other; the former should be the basis of individual information on the concrete treatment, provided by the physician in a mandatory oral conversation with the patient. Product information cannot replace the physician's individual information about the treatment.

  19. Patient Safety Walkaround: a communication tool for the reallocation of health service resources: An Italian experience of safety healthcare implementation.

    PubMed

    Ferorelli, Davide; Zotti, Fiorenza; Tafuri, Silvio; Pezzolla, Angela; Dell'Erba, Alessandro

    2016-10-01

    The study aims to evaluate the use of Patient Safety Walkaround (SWR) execution model in an Italian Hospital, through the adoption of parametric indices, survey tools, and process indicators.In the 1st meeting an interview was conducted to verify the knowledge of concepts of clinical risk management (process indicators). One month after, the questions provided by Frankel (survey tool) were administered.Each month after, an SWR has been carried trying to assist the healthcare professionals and collecting suggestions and solutions.Results have been classified according to Vincent model and analyzed to define an action plan. The amount of risk was quantified by the risk priority index (RPI).An organizational deficit concerns the management of the operating theatre.A state of intolerance was noticed of queuing patients for outpatient visits. The lack of scheduling of the operating rooms is often the cause of sudden displacements. A consequence is the conflict between patients and caregivers. Other causes of the increase of waiting times are the presence in the ward of a single trolley for medications and the presence of a single room for admission and preadmission of patients.Patients victims of allergic reactions have attributed such reactions to the presence of other patients in the process of acceptance and collection of medical history.All health professionals have reported the problem of n high number of relatives of the patients in the wards.Our study indicated the consistency of SWR as instrument to improve the quality of the care.

  20. A Secure ECC-based RFID Mutual Authentication Protocol to Enhance Patient Medication Safety.

    PubMed

    Jin, Chunhua; Xu, Chunxiang; Zhang, Xiaojun; Li, Fagen

    2016-01-01

    Patient medication safety is an important issue in patient medication systems. In order to prevent medication errors, integrating Radio Frequency Identification (RFID) technology into automated patient medication systems is required in hospitals. Based on RFID technology, such systems can provide medical evidence for patients' prescriptions and medicine doses, etc. Due to the mutual authentication between the medication server and the tag, RFID authentication scheme is the best choice for automated patient medication systems. In this paper, we present a RFID mutual authentication scheme based on elliptic curve cryptography (ECC) to enhance patient medication safety. Our scheme can achieve security requirements and overcome various attacks existing in other schemes. In addition, our scheme has better performance in terms of computational cost and communication overhead. Therefore, the proposed scheme is well suitable for patient medication systems.

  1. [The contribution of critical laboratory values to patients' safety and care].

    PubMed

    Guzmán D, Ana María; Lagos L, Marcela

    2009-04-01

    Critical values are those laboratory values that are so abnormal that may threaten the life of a patient unless immediate corrective or therapeutic actions are undertaken. Among laboratory procedures, this definition has been incorporated to standards that watch over patients' safety. Health institutions should incorporate this practice and monitor its effectiveness.

  2. A Comprehensive Approach to Identifying Intervention Targets for Patient-Safety Improvement in a Hospital Setting

    ERIC Educational Resources Information Center

    Cunningham, Thomas R.; Geller, E. Scott

    2012-01-01

    Despite differences in approaches to organizational problem solving, healthcare managers and organizational behavior management (OBM) practitioners share a number of practices, and connecting healthcare management with OBM may lead to improvements in patient safety. A broad needs-assessment methodology was applied to identify patient-safety…

  3. Update on the National Patient Safety Goals - changes for 2006.

    PubMed

    McMaster, Janet

    2005-01-01

    Compliance with the NPSGs is mandatory for an organization that seeks JCAHO accreditation. Beyond compliance with goals simply for survey purposes, hospitals that provide care to trauma patients should attempt to make the care of the patient as safe as possible by anticipating problems and complications, and avoiding them if possible.

  4. Pharmaceutical orientation at hospital discharge of transplant patients: strategy for patient safety

    PubMed Central

    Lima, Lívia Falcão; Martins, Bruna Cristina Cardoso; de Oliveira, Francisco Roberto Pereira; Cavalcante, Rafaela Michele de Andrade; Magalhães, Vanessa Pinto; Firmino, Paulo Yuri Milen; Adriano, Liana Silveira; da Silva, Adriano Monteiro; Flor, Maria Jose Nascimento; Néri, Eugenie Desirée Rabelo

    2016-01-01

    ABSTRACT Objective: To describe and analyze the pharmaceutical orientation given at hospital discharge of transplant patients. Methods: This was a cross-sectional, descriptive and retrospective study that used records of orientation given by the clinical pharmacist in the inpatients unit of the Kidney and Liver Transplant Department, at Hospital Universitário Walter Cantídio, in the city of Fortaleza (CE), Brazil, from January to July, 2014. The following variables recorded at the Clinical Pharmacy Database were analyzed according to their significance and clinical outcomes: pharmaceutical orientation at hospital discharge, drug-related problems and negative outcomes associated with medication, and pharmaceutical interventions performed. Results: The first post-transplant hospital discharge involved the entire multidisciplinary team and the pharmacist was responsible for orienting about drug therapy. The mean hospital discharges/month with pharmaceutical orientation during the study period was 10.6±1.3, totaling 74 orientations. The prescribed drug therapy had a mean of 9.1±2.7 medications per patient. Fifty-nine drug-related problems were identified, in which 67.8% were related to non-prescription of medication needed, resulting in 89.8% of risk of negative outcomes associated with medications due to untreated health problems. The request for inclusion of drugs (66.1%) was the main intervention, and 49.2% of the medications had some action in the digestive tract or metabolism. All interventions were classified as appropriate, and 86.4% of them we able to prevent negative outcomes. Conclusion: Upon discharge of a transplanted patient, the orientation given by the clinical pharmacist together with the multidisciplinary team is important to avoid negative outcomes associated with drug therapy, assuring medication reconciliation and patient safety. PMID:27759824

  5. Patient and healthcare perspectives on the importance and efficacy of addressing spiritual issues within an interdisciplinary bone marrow transplant clinic: a qualitative study

    PubMed Central

    Sinclair, Shane; McConnell, Shelagh; Raffin Bouchal, Shelley; Ager, Naree; Booker, Reanne; Enns, Bert; Fung, Tak

    2015-01-01

    Objectives The purpose of this study was to use a qualitative approach to better understand the importance and efficacy of addressing spiritual issues within an interdisciplinary bone marrow transplant clinic from the perspectives of patients and healthcare providers. Setting Participants were recruited from the bone marrow transplant clinic of a large urban outpatient cancer care centre in western Canada. Participants: Focus groups were conducted with patients (n=7) and healthcare providers (n=9) to explore the importance of addressing spiritual issues across the treatment trajectory and to identify factors associated with effectively addressing these needs. Results Data were analysed using the qualitative approach of latent content analysis. Addressing spiritual issues was understood by patients and healthcare providers, as a core, yet under addressed, component of comprehensive care. Both sets of participants felt that addressing basic spiritual issues was the responsibility of all members of the interdisciplinary team, while recognising the need for specialised and embedded support from a spiritual care professional. While healthcare providers felt that the impact of the illness and treatment had a negative effect on patients’ spiritual well-being, patients felt the opposite. Skills, challenges, key time points and clinical indicators associated with addressing spiritual issues were identified. Conclusions Despite a number of conceptual and clinical challenges associated with addressing spiritual issues patients and their healthcare providers emphasised the importance of an integrated approach whereby basic spiritual issues are addressed by members of the interdisciplinary team and by an embedded spiritual care professional, who in addition also provides specialised support. The identification of clinical issues associated with addressing spiritual needs provides healthcare providers with clinical guidance on how to better integrate this aspect of care into

  6. Applying the WHO conceptual framework for the International Classification for Patient Safety to a surgical population

    PubMed Central

    McElroy, L. M.; Woods, D. M.; Yanes, A. F.; Skaro, A. I.; Daud, A.; Curtis, T.; Wymore, E.; Holl, J. L.; Abecassis, M. M.; Ladner, D. P.

    2016-01-01

    Objective Efforts to improve patient safety are challenged by the lack of universally agreed upon terms. The International Classification for Patient Safety (ICPS) was developed by the World Health Organization for this purpose. This study aimed to test the applicability of the ICPS to a surgical population. Design A web-based safety debriefing was sent to clinicians involved in surgical care of abdominal organ transplant patients. A multidisciplinary team of patient safety experts, surgeons and researchers used the data to develop a system of classification based on the ICPS. Disagreements were reconciled via consensus, and a codebook was developed for future use by researchers. Results A total of 320 debriefing responses were used for the initial review and codebook development. In total, the 320 debriefing responses contained 227 patient safety incidents (range: 0–7 per debriefing) and 156 contributing factors/hazards (0–5 per response). The most common severity classification was ‘reportable circumstance,’ followed by ‘near miss.’ The most common incident types were ‘resources/organizational management,’ followed by ‘medical device/equipment.’ Several aspects of surgical care were encompassed by more than one classification, including operating room scheduling, delays in care, trainee-related incidents, interruptions and handoffs. Conclusions This study demonstrates that a framework for patient safety can be applied to facilitate the organization and analysis of surgical safety data. Several unique aspects of surgical care require consideration, and by using a standardized framework for describing concepts, research findings can be compared and disseminated across surgical specialties. The codebook is intended for use as a framework for other specialties and institutions. PMID:26803539

  7. Status of patient safety culture in Arab countries: a systematic review

    PubMed Central

    Almashrafi, Ahmed; Banarsee, Ricky

    2017-01-01

    Objectives To explore the status of patient safety culture in Arab countries based on the findings of the Hospital Survey on Patient Safety Culture (HSPSC). Design Systematic review. Methods We performed electronic searches of the MEDLINE, EMBASE, CINAHL, ProQuest and PsychINFO, Google Scholar and PubMed databases, with manual searches of bibliographies of included articles and key journals. We included studies that were conducted in the Arab countries that were focused on patient safety culture. 2 reviewers independently verified that the studies met the inclusion criteria and critically assessed the quality of the studies. Results 18 studies met our inclusion criteria. The review identified that non-punitive response to error is seen as a serious issue which needs to be improved. Healthcare professionals in the Arab countries tend to think that a ‘culture of blame’ still exists that prevents them from reporting incidents. We found an overall similarity between the reported composite score for dimension of teamwork within units in all of the reviewed studies. Teamwork within units was found to be better than teamwork across hospital units. All of the reviewed studies reported that organisational learning and continuous improvement was satisfactory as the average score of this dimension for all studies was 73.2%. Moreover, the review found that communication openness seems to be a concerning issue for healthcare professionals in the Arab countries. Conclusions There is a need to promote patient safety culture as a strategy for improving the patient safety in the Arab world. Improving patient safety culture should include all stakeholders, like policymakers, healthcare providers and those responsible for medical education. This review was limited only to English language publications. The varied settings in which the HSPSC was used may have influenced the areas of strengths and weaknesses as healthcare workers' perception of safety culture may differ. PMID

  8. Counterheroism, Common Knowledge, and Ergonomics: Concepts from Aviation That Could Improve Patient Safety

    PubMed Central

    Lewis, Geraint H; Vaithianathan, Rhema; Hockey, Peter M; Hirst, Guy; Bagian, James P

    2011-01-01

    Context: Many safety initiatives have been transferred successfully from commercial aviation to health care. This article develops a typology of aviation safety initiatives, applies this to health care, and proposes safety measures that might be adopted more widely. It then presents an economic framework for determining the likely costs and benefits of different patient safety initiatives. Methods: This article describes fifteen examples of error countermeasures that are used in public transport aviation, many of which are not routinely used in health care at present. Examples are the sterile cockpit rule, flight envelope protection, the first-names-only rule, and incentivized no-fault reporting. It develops a conceptual schema that is then used to argue why analogous initiatives might be usefully applied to health care and why physicians may resist them. Each example is measured against a set of economic criteria adopted from the taxation literature. Findings: The initiatives considered in the article fall into three themes: safety concepts that seek to downplay the role of heroic individuals and instead emphasize the importance of teams and whole organizations; concepts that seek to increase and apply group knowledge of safety information and values; and concepts that promote safety by design. The salient costs to be considered by organizations wishing to adopt these suggestions are the compliance costs to clinicians, the administration costs to the organization, and the costs of behavioral distortions. Conclusions: This article concludes that there is a range of safety initiatives used in commercial aviation that could have a positive impact on patient safety, and that adopting such initiatives may alter the safety culture of health care teams. The desirability of implementing each initiative, however, depends on the projected costs and benefits, which must be assessed for each situation. PMID:21418311

  9. Carotid endarterectomy in awake patients: safety, tolerability and results

    PubMed Central

    Mendonça, Célio Teixeira; Fortunato Jr, Jerônimo A.; de Carvalho, Cláudio A.; Weingartner, Janaina; Filho, Otávio R. M.; Rezende, Felipe F.; Bertinato, Luciane P.

    2014-01-01

    Objective To analyze the results of 125 carotid endarterectomies under loco-regional anesthesia, with selective use of shunt and bovine pericardium patch. Methods One hundred and seventeen patients with stenosis ≥ 70% in the internal carotid artery on duplex-scan + arteriography or magnetic resonance angiography underwent 125 carotid endarterectomies. Intraoperative pharmacological cerebral protection included intravenous administration of alfentanil and dexametasone. Clopidogrel, aspirin and statins were used in all cases. Seventy-seven patients were males (65.8%). Mean age was 70.8 years, ranging from 48 to 88 years. Surgery was performed to treat symptomatic stenosis in 69 arteries (55.2%) and asymptomatic stenosis in 56 arteries (44.8%). Results A carotid shunt was used in 3 cases (2.4%) due to signs and symptoms of cerebral ischemia after carotid artery clamping during the operation, and all 3 patients had a good outcome. Bovine pericardium patch was used in 71 arteries ≤ 6 mm in diameter (56.8%). Perioperative mortality was 0.8%: one patient died from a myocardial infarction. Two patients (1.6%) had minor ipsilateral strokes with good recovery, and 2 patients (1.6%) had non-fatal myocardial infarctions with good recovery. The mean follow-up period was 32 months. In the late postoperative period, there was restenosis in only three arteries (2.4%). Conclusion Carotid artery endarterectomy can be safely performed in the awake patient, with low morbidity and mortality rates. PMID:25714212

  10. The economic burden of patient safety targets in acute care: a systematic review

    PubMed Central

    Mittmann, Nicole; Koo, Marika; Daneman, Nick; McDonald, Andrew; Baker, Michael; Matlow, Anne; Krahn, Murray; Shojania, Kaveh G; Etchells, Edward

    2012-01-01

    Background Our objective was to determine the quality of literature in costing of the economic burden of patient safety. Methods We selected 15 types of patient safety targets for our systematic review. We searched the literature published between 2000 and 2010 using the following terms: “costs and cost analysis,” “cost-effectiveness,” “cost,” and “financial management, hospital.” We appraised the methodologic quality of potentially relevant studies using standard economic methods. We recorded results in the original currency, adjusted for inflation, and then converted to 2010 US dollars for comparative purposes (2010 US$1.00 = 2010 €0.76). The quality of each costing study per patient safety target was also evaluated. Results We screened 1948 abstracts, and identified 158 potentially eligible studies, of which only 61 (39%) reported any costing methodology. In these 61 studies, we found wide estimates of the attributable costs of patient safety events ranging from $2830 to $10,074. In general hospital populations, the cost per case of hospital-acquired infection ranged from $2132 to $15,018. Nosocomial bloodstream infection was associated with costs ranging from $2604 to $22,414. Conclusion There are wide variations in the estimates of economic burden due to differences in study methods and methodologic quality. Greater attention to methodologic standards for economic evaluations in patient safety is needed. PMID:23097615

  11. Near-peers improve patient safety training in the preclinical curriculum

    PubMed Central

    Raty, Sally R.; Teal, Cayla R.; Nelson, Elizabeth A.; Gill, Anne C.

    2017-01-01

    ABSTRACT Background: Accrediting bodies require medical schools to teach patient safety and residents to develop teaching skills in patient safety. We created a patient safety course in the preclinical curriculum and used continuous quality improvement to make changes over time. Objective: To assess the impact of resident teaching on student perceptions of a Patient Safety course. Design: Using the Institute for Healthcare Improvement patient safety curriculum as a frame, the course included the seven IHI modules, large group lectures and small group facilitated discussions. Applying a social action methodology, we evaluated the course for four years (Y1–Y4). Results: In Y1, Y2, Y3 and Y4, we distributed a course evaluation to each student (n = 184, 189, 191, and 184, respectively) and the response rate was 96, 97, 95 and 100%, respectively. Overall course quality, clarity of course goals and value of small group discussions increased in Y2 after the introduction of residents as small group facilitators. The value of residents and the overall value of the course increased in Y3 after we provided residents with small group facilitation training. Conclusions: Preclinical students value the interaction with residents and may perceive the overall value of a course to be improved based on near-peer involvement. Residents gain valuable experience in small group facilitation and leadership. PMID:28219315

  12. Twelve- and 52-week safety of albuterol multidose dry powder inhaler in patients with persistent asthma

    PubMed Central

    Raphael, Gordon; Taveras, Herminia; Iverson, Harald; O’Brien, Christopher; Miller, David

    2016-01-01

    Abstract Objective: Evaluate the safety of albuterol multidose dry powder inhaler (MDPI), a novel, inhalation-driven device that does not require coordination of actuation with inhalation, in patients with persistent asthma. Methods: We report pooled safety data from two 12-week, multicenter, randomized, double-blind, repeat-dose, parallel-group studies and the 12-week double-blind phase of a 52-week multicenter safety study as well as safety data from the 40-week open-label phase of the 52-week safety study. In each study, eligible patients aged ≥12 years with persistent asthma received placebo MDPI or albuterol MDPI 180 µg (2 inhalations × 90 µg/inhalation) 4 times/day for 12 weeks. In the 40-week open-label phase of the 52-week safety study, patients received albuterol MDPI 180 μg (2 inhalations × 90 μg/inhalation) as needed (PRN). Results: During both 12-week studies and the 12-week double-blind phase of the 52-week study, adverse events were more common with placebo MDPI (50%; n = 333) than albuterol MDPI (40%; n = 321); most frequent were upper respiratory tract infection (placebo MDPI 11%, albuterol MDPI 10%), nasopharyngitis (6%, 5%), and headache (6%, 4%). Incidences of β2-agonist-related events (excluding headache) during the pooled 12-week dosing periods were low (≤1%) in both groups. The safety profile with albuterol MDPI PRN during the 40-week open-label phase [most frequent adverse events: nasopharyngitis (12%), sinusitis (11%), upper respiratory tract infection (9%)] was similar to that observed during the 12-week pooled analysis. Conclusions: The safety profile of albuterol MDPI 180 μg in these studies was comparable with placebo MDPI and consistent with the well-characterized profile of albuterol in patients with asthma. PMID:26369589

  13. Retrieval medicine: a review and guide for UK practitioners. Part 2: safety in patient retrieval systems

    PubMed Central

    Hearns, S; Shirley, P J

    2006-01-01

    Retrieval and transfer of critically ill and injured patients is a high risk activity. Risk can be minimised with robust safety and clinical governance systems in place. This article describes the various governance systems that can be employed to optimise safety and efficiency in retrieval services. These include operating procedure development, equipment management, communications procedures, crew resource management, significant event analysis, audit and training. PMID:17130608

  14. On SHiPs and safety: a journey of safe patient handling in pediatrics.

    PubMed

    Huffman, Gayla M; Crumrine, Jean; Thompson, Brenda; Mobley, Venise; Roth, Katie; Roberts, Cristine

    2014-01-01

    Nursing personnel have consistently been ranked among the top ten professions impacted by musculoskeletal injuries. Inpatient pediatric nurses witnessed an increase in injuries and upon discovering limited evidence applicable to pediatrics, conducted a research study to evaluate the effectiveness of a safe patient handling program. Surveys were distributed to assess risk and workplace safety perceptions. Post-implementation, surveys revealed a statistically significant (p>0.0001) increase in staff perception of workplace safety, reduction in risk perception for several nursing tasks, and reduction in injury related costs. As a result of this program, workplace safety was improved through education and equipment provision.

  15. HAI prevention emphasized in 2009 National Patient Safety Goals.

    PubMed

    2008-09-01

    * Having an infection control program already in place does no ensure compliance with new NPSGs. * Patient involvement, education are critical components in preventing HAIs. * New requirements mean more levels of documentation.

  16. Patient safety is not enough: targeting quality improvements to optimize the health of the population.

    PubMed

    Woolf, Steven H

    2004-01-06

    Ensuring patient safety is essential for better health care, but preoccupation with niches of medicine, such as patient safety, can inadvertently compromise outcomes if it distracts from other problems that pose a greater threat to health. The greatest benefit for the population comes from a comprehensive view of population needs and making improvements in proportion with their potential effect on public health; anything less subjects an excess of people to morbidity and death. Patient safety, in context, is a subset of health problems affecting Americans. Safety is a subcategory of medical errors, which also includes mistakes in health promotion and chronic disease management that cost lives but do not affect "safety." These errors are a subset of lapses in quality, which result not only from errors but also from systemic problems, such as lack of access, inequity, and flawed system designs. Lapses in quality are a subset of deficient caring, which encompasses gaps in therapeutics, respect, and compassion that are undetected by normative quality indicators. These larger problems arguably cost hundreds of thousands more lives than do lapses in safety, and the system redesigns to correct them should receive proportionately greater emphasis. Ensuring such rational prioritization requires policy and medical leaders to eschew parochialism and take a global perspective in gauging health problems. The public's well-being requires policymakers to view the system as a whole and consider the potential effect on overall population health when prioritizing care improvements and system redesigns.

  17. Assessment of patient safety culture in clinical laboratories in the Spanish National Health System

    PubMed Central

    Giménez-Marín, Angeles; Rivas-Ruiz, Francisco; García-Raja, Ana M.; Venta-Obaya, Rafael; Fusté-Ventosa, Margarita; Caballé-Martín, Inmaculada; Benítez-Estevez, Alfonso; Quinteiro-García, Ana I.; Bedini, José Luis; León-Justel, Antonio; Torra-Puig, Montserrat

    2015-01-01

    Introduction There is increasing awareness of the importance of transforming organisational culture in order to raise safety standards. This paper describes the results obtained from an evaluation of patient safety culture in a sample of clinical laboratories in public hospitals in the Spanish National Health System. Material and methods A descriptive cross-sectional study was conducted among health workers employed in the clinical laboratories of 27 public hospitals in 2012. The participants were recruited by the heads of service at each of the participating centers. Stratified analyses were performed to assess the mean score, standardized to a base of 100, of the six survey factors, together with the overall patient safety score. Results 740 completed questionnaires were received (88% of the 840 issued). The highest standardized scores were obtained in Area 1 (individual, social and cultural) with a mean value of 77 (95%CI: 76-78), and the lowest ones, in Area 3 (equipment and resources), with a mean value of 58 (95%CI: 57-59). In all areas, a greater perception of patient safety was reported by the heads of service than by other staff. Conclusions We present the first multicentre study to evaluate the culture of clinical safety in public hospital laboratories in Spain. The results obtained evidence a culture in which high regard is paid to safety, probably due to the pattern of continuous quality improvement. Nevertheless, much remains to be done, as reflected by the weaknesses detected, which identify areas and strategies for improvement. PMID:26525595

  18. Understanding situation awareness and its importance in patient safety.

    PubMed

    Gluyas, Heather; Harris, Sarah-Jane

    2016-04-20

    Situation awareness describes an individual's perception, comprehension and subsequent projection of what is going on in the environment around them. The concept of situation awareness sits within the group of non-technical skills that include teamwork, communication and managing hierarchical lines of communication. The importance of non-technical skills has been recognised in safety-critical industries such as aviation, the military, nuclear, and oil and gas. However, health care has been slow to embrace the role of non-technical skills such as situation awareness in improving outcomes and minimising the risk of error. This article explores the concept of situation awareness and the cognitive processes involved in maintaining it. In addition, factors that lead to a loss of situation awareness and strategies to improve situation awareness are discussed.

  19. Safety of tianeptine use in patients with epilepsy.

    PubMed

    Moon, Jangsup; Jung, Keun-Hwa; Shin, Jung-Won; Lim, Jung-Ah; Byun, Jung-Ick; Lee, Soon-Tae; Chu, Kon; Lee, Sang Kun

    2014-05-01

    Depression is a frequent comorbidity in patients with epilepsy (PWE). However, it is often undertreated because of concerns of seizure exacerbation by antidepressant treatment. The effect of tianeptine on seizure frequency is not known as yet. Thus, we aimed to evaluate the influence of tianeptine on the seizure frequency in PWE. We retrospectively reviewed the medical records of PWE who received tianeptine between January 2006 and June 2013 at the Epilepsy Center of Seoul National University Hospital. Patients were excluded if the dose or type of antiepileptic drugs (AEDs) they took was altered at the start of tianeptine treatment or if the treatment period of tianeptine was <3 months. A total of 74 PWE were enrolled in our study (male: 32, mean age: 41.9±14.5). Sixty-nine patients had localization-related epilepsy, and 5 had idiopathic generalized epilepsy (IGE). Mean seizure frequency during the 3-month period just after tianeptine exposure was compared with the baseline seizure frequency, which showed no change in 69 (93.2%) patients, decrease in 2 (2.7%) patients, and increase in 3 patients (4.1%). The type of epileptic syndrome, the baseline seizure frequency, and the number of coadministered AEDs did not influence the change in seizure frequency after tianeptine prescription. Change in seizure frequency did not differ between the patients given tianeptine as an additive antidepressant and those given tianeptine as a replacement antidepressant. Our data suggest that tianeptine can be prescribed safely to PWE with depression without increasing the seizure frequency regardless of the baseline severity of epilepsy. Tianeptine may be actively considered as a first-choice antidepressant or as an alternative antidepressant in PWE with depression.

  20. Emerging issues in improving food and physical activity environments: strategies for addressing land use, transportation, and safety in 3 California-wide initiatives.

    PubMed

    Aboelata, Manal J; Navarro, Amanda M

    2010-11-01

    Mounting research has suggested linkages between neighborhood safety, community design, and transportation patterns and eating and activity behaviors and health outcomes. On the basis of a review of evaluation findings from 3 multisite healthy eating and activity initiatives in California, we provide an overview of 3 community process strategies-engaging local advocates, linking safety to health, and collaborating with local government officials-that may be associated with the successful development and implementation of long-term community-improvement efforts and should be explored further.

  1. Strengthening leadership as a catalyst for enhanced patient safety culture: a repeated cross-sectional experimental study

    PubMed Central

    Kristensen, Solvejg; Christensen, Karl Bang; Jaquet, Annette; Møller Beck, Carsten; Sabroe, Svend; Bartels, Paul; Mainz, Jan

    2016-01-01

    Objectives Current literature emphasises that clinical leaders are in a position to enable a culture of safety, and that the safety culture is a performance mediator with the potential to influence patient outcomes. This paper aims to investigate staff's perceptions of patient safety culture in a Danish psychiatric department before and after a leadership intervention. Methods A repeated cross-sectional experimental study by design was applied. In 2 surveys, healthcare staff were asked about their perceptions of the patient safety culture using the 7 patient safety culture dimensions in the Safety Attitudes Questionnaire. To broaden knowledge and strengthen leadership skills, a multicomponent programme consisting of academic input, exercises, reflections and discussions, networking, and action learning was implemented among the clinical area level leaders. Results In total, 358 and 325 staff members participated before and after the intervention, respectively. 19 of the staff members were clinical area level leaders. In both surveys, the response rate was >75%. The proportion of frontline staff with positive attitudes improved by ≥5% for 5 of the 7 patient safety culture dimensions over time. 6 patient safety culture dimensions became more positive (increase in mean) (p<0.05). Frontline staff became more positive on all dimensions except stress recognition (p<0.05). For the leaders, the opposite was the case (p<0.05). Staff leaving the department after the first measurement had rated job satisfaction lower than the staff staying on (p<0.05). Conclusions The improvements documented in the patient safety culture are remarkable, and imply that strengthening the leadership can act as a significant catalyst for patient safety culture improvement. Further studies using a longitudinal study design are recommended to investigate the mechanism behind leadership's influence on patient safety culture, sustainability of improvements over time, and the association of change

  2. [Development and validation of indicators for best patient safety practices: the ISEP-Brazil Project].

    PubMed

    Gama, Zenewton André da Silva; Saturno-Hernández, Pedro Jesus; Ribeiro, Denise Nieuwenhoff Cardoso; Freitas, Marise Reis de; Medeiros, Paulo José de; Batista, Almária Mariz; Barreto, Analúcia Filgueira Gouveia; Lira, Benize Fernandes; Medeiros, Carlos Alexandre de Souza; Vasconcelos, Cilane Cristina Costa da Silva; Silva, Edna Marta Mendes da; Faria, Eduardo Dantas Baptista de; Dantas, Jane Francinete; Neto, José Gomes; Medeiros, Luana Cristina Lins de; Sicolo, Miguel Angel; Fonseca, Patrícia de Cássia Bezerra; Costa, Rosângela Maria Morais da; Monte, Francisca Sueli; Melo, Veríssimo de

    2016-09-19

    Efficacious patient safety monitoring should focus on the implementation of evidence-based practices that avoid unnecessary harm related to healthcare. The ISEP-Brazil project aimed to develop and validate indicators for best patient safety practices in Brazil. The basis was the translation and adaptation of the indicators validated in the ISEP-Spain project and the document Safe Practices for Better Healthcare (U.S. National Quality Forum), recommending 34 best practices. A 25-member expert panel validated the indicators. Reliability and feasibility were based on a pilot study in three hospitals with different management formats (state, federal, and private). Seventy-five best practice indicators were approved (39 structure; 36 process) for 31 of the 34 recommendations. The indicators were considered valid, reliable, and useful for monitoring patient safety in Brazilian hospitals.

  3. [Helsinki Declaration on Patient Safety in Anaesthesiology--Part 8: SOP for checking equipment and drugs].

    PubMed

    Happel, Oliver; Roewer, Norbert; Kranke, Peter

    2013-09-01

    In 2010 the Helsinki Declaration on Patient Safety in Anaesthesiology was launched. In this joined statement under the auspice of the European Society of Anaesthesiology the need for protocols for different aspects of perioperative procedures that could affect patient safety was stated. All participating institutions should have--among others--protocols for checking equipment and drugs required for the delivery of safe anaesthesia. The background for this being the fact that the lack of carefully checking equipment and drugs--or not adhering to existing checklists--is a latent threat to patient safety and thus may increase morbidity and mortality.In this part of a series the authors present protocols existing in their clinic for checking anaesthesia equipment and drugs.

  4. Centralized video monitoring for patient safety: a Denver Health Lean journey.

    PubMed

    Jeffers, Sharon; Searcey, Phebe; Boyle, Kathy; Herring, Carol; Lester, Kathleen; Goetz-Smith, Hillarie; Nelson, Polly

    2013-01-01

    The demand for certified nursing assistant (CNA) staff used as 1:1 sitters for safety enhancement and fall prevention can be costly. Through Lean thinking and tools and brainstorming, leaders at Denver Health conceptualized the centralized video monitoring (CVM) program for patient safety. The CVM program reallocated the underutilized talents of CNA sitters as video monitoring technicians (VMT) to meet the challenge of delivering high-quality, cost-effective patient care. Implementing the CVM program required tight connections and collaboration with a multidisciplinary team of individuals. Actual program performance exceeded the initial projected benefits. The CVM program supports the high level of vigilance required by nursing staff to ensure patient safety and quality.

  5. Attitude of primary care physicians toward patient safety in Aseer region, Saudi Arabia

    PubMed Central

    Al-Khaldi, Yahia M.

    2013-01-01

    Objective: The objective of this study was to assess the attitude of physicians at primary health-care centers (PHCC) in Aseer region toward patient safety. Materials and Methods: This study was conducted among working primary health-care physicians in Aseer region, Saudi Arabia, in August 2011. A self-administered questionnaire consisting of three parts was used; the first part was on the socio-demographic, academic and about the work profile of the participants. The attitude consisting of 26 questions was assessed on a Likert scale of 7 points using attitude to patients safety questionnaire-III items and the last part concerned training on “patient safety”, definition and factors that contribute to medical errors. Data of the questionnaire were entered and analyzed by Statistical Package for the Social Sciences (SPSS) version 15. Results: The total number of participants was 228 doctors who represent about 65% of the physicians at PHCC, one-third of whom had attended a course on patient safety and only 52% of whom defined medical error correctly. The best score was given for the reduction of medical errors (6.2 points), followed by role of training and learning on patient safety (6 and 5.9 points), but undergraduate training on patient safety was given the least score. Confidence to report medical errors scored 4.6 points as did reporting the errors of other people and 5.6 points for being open with the supervisor about an error made. Participants agreed that “even the most experienced and competent doctors make errors” (5.9 points), on the other hand, they disagreed that most medical errors resulted from nurses’ carelessness (3.9 points) or doctors’ carelessness (4 points). Conclusion: This study showed that PHCC physicians in Aseer region had a positive attitude toward patient safety. Most of them need training on patient safety. Undergraduate education on patient safety which was considered a priority for making future doctors’ work effective was

  6. Introduction to the STS National Database Series: Outcomes Analysis, Quality Improvement, and Patient Safety.

    PubMed

    Jacobs, Jeffrey P; Shahian, David M; Prager, Richard L; Edwards, Fred H; McDonald, Donna; Han, Jane M; D'Agostino, Richard S; Jacobs, Marshall L; Kozower, Benjamin D; Badhwar, Vinay; Thourani, Vinod H; Gaissert, Henning A; Fernandez, Felix G; Wright, Cam; Fann, James I; Paone, Gaetano; Sanchez, Juan A; Cleveland, Joseph C; Brennan, J Matthew; Dokholyan, Rachel S; O'Brien, Sean M; Peterson, Eric D; Grover, Frederick L; Patterson, G Alexander

    2015-12-01

    The Society of Thoracic Surgeons (STS) National Database is the foundation for most of the Society's quality, research, and patient safety activities. Beginning in January 2016 and repeating each year, The Annals of Thoracic Surgery will publish a monthly Database series of scholarly articles on outcomes analysis, quality improvement, and patient safety. Six articles will be directly derived from the STS National Database and will be published every other month: three articles on outcomes and quality (one each from the STS Adult Cardiac Surgery Database, the STS Congenital Heart Surgery Database, and the STS General Thoracic Surgery Database), and three articles on research (one from each of these three specialty databases). These six articles will alternate with five additional articles on topics related to patient safety. The final article, to be published in December, will provide a summary of the prior 11 manuscripts. This series will allow STS and its Workforces on National Databases, Research Development, and Patient Safety to convey timely information aimed at improving the quality and safety of cardiothoracic surgery.

  7. Impact of Pharmacy-Led Dyslipidemia Interventions on Medication Safety and Therapeutic Failure in Patients

    DTIC Science & Technology

    2005-05-01

    pharmacist-run patient education /polypharmacy clinic was developed. This clinic served as one venue to support medication access issues and address...as well as community physicians. Until the lipid clinic was implemented, the patient education /polypharmacy clinic served as the primary...with a variety of patient education materials concerning cardiovascular disease and patient compliance, as well as materials on other disease states

  8. Addressing healthcare.

    PubMed

    Daly, Rich

    2013-02-11

    Though President Barack Obama has rarely made healthcare references in his State of the Union addresses, health policy experts are hoping he changes that strategy this year. "The question is: Will he say anything? You would hope that he would, given that that was the major issue he started his presidency with," says Dr. James Weinstein, left, of the Dartmouth-Hitchcock health system.

  9. Financial and Demographic Influences on Medicare Patient Safety Events

    DTIC Science & Technology

    2005-01-01

    decubitus ulcers (the remaining 2 of the 14 PSIs), as well as aspiration pneumonia, atelectasis (i.e., iatrogenic lung collapse), and urinary tract...Descriptive statistics, cont. Variables Means Patient Chronic Conditions, cont.: Liver Disease 0.007 Peptic Ulcer Disease X Bleeding 0.010 AIDS

  10. Safe patient care – safety culture and risk management in otorhinolaryngology

    PubMed Central

    St. Pierre, Michael

    2013-01-01

    Safety culture is positioned at the heart of an organization’s vulnerability to error because of its role in framing organizational awareness to risk and in providing and sustaining effective strategies of risk management. Safety related attitudes of leadership and management play a crucial role in the development of a mature safety culture (“top-down process”). A type marker for organizational culture and thus a predictor for an organization’s maturity in respect to safety is information flow and in particular an organization’s general way of coping with information that suggests anomaly. As all values and beliefs, relationships, learning, and other aspects of organizational safety culture are about sharing and processing information, safety culture has been termed “informed culture”. An informed culture is free of blame and open for information provided by incidents. “Incident reporting systems” are the backbone of a reporting culture, where good information flow is likely to support and encourage other kinds of cooperative behavior, such as problem solving, innovation, and inter-departmental bridging. Another facet of an informed culture is the free flow of information during perioperative patient care. The World Health Organization’s safe surgery checklist” is the most prevalent example of a standardized information exchange aimed at preventing patient harm due to information deficit. In routine tasks mandatory standard operating procedures have gained widespread acceptance in guaranteeing the highest possible process quality. Technical and non-technical skills of healthcare professionals are the decisive human resource for an efficient and safe delivery of patient care and the avoidance of errors. The systematic enhancement of staff qualification by providing training opportunities can be a major investment in patient safety. In recent years several otorhinolaryngology departments have started to incorporate stimulation based team

  11. MRI safety: a report of current practice and advancements in patient preparation and screening.

    PubMed

    Weidman, Elizabeth K; Dean, Kathryn E; Rivera, William; Loftus, Michael L; Stokes, Thomas W; Min, Robert J

    2015-01-01

    MRI offers detailed diagnostic images without ionizing radiation; however, there are considerable safety concerns associated with high electromagnetic field strength. With increasing use of high and ultra high (7T) magnetic field strength, adequate patient preparation and screening for ferrous material is increasingly important. We review current safety standards for patient screening and preparation and how they are implemented at our institution. In addition, we describe a novel supplemental screening technique wherein the lights are dimmed in response to detected ferrous metal at the threshold of Zone IV.

  12. Nurses' Use of Computerized Clinical Guidelines to Improve Patient Safety in Hospitals.

    PubMed

    Hovde, Birgit; Jensen, Kari H; Alexander, Gregory L; Fossum, Mariann

    2015-07-01

    Computerized clinical guidelines are frequently used to translate research into evidence-based behavioral practices and to improve patient outcomes. The purpose of this integrative review is to summarize the factors influencing nurses' use of computerized clinical guidelines and the effects of nurses' use of computerized clinical guidelines on patient safety improvements in hospitals. The Embase, Medline Complete, and Cochrane databases were searched for relevant literature published from 2000 to January 2013. The matrix method was used, and a total of 16 papers were included in the final review. The studies were assessed for quality with the Critical Appraisal Skills Program. The studies focused on nurses' adherence to guidelines and on improved patient care and patient outcomes as benefits of using computerized clinical guidelines. The nurses' use of computerized clinical guidelines demonstrated improvements in care processes; however, the evidence for an effect of computerized clinical guidelines on patient safety remains limited.

  13. Patient-Reported Outcome Measures in Safety Event Reporting: PROSPER Consortium guidance.

    PubMed

    Banerjee, Anjan K; Okun, Sally; Edwards, I Ralph; Wicks, Paul; Smith, Meredith Y; Mayall, Stephen J; Flamion, Bruno; Cleeland, Charles; Basch, Ethan

    2013-12-01

    The Patient-Reported Outcomes Safety Event Reporting (PROSPER) Consortium was convened to improve safety reporting by better incorporating the perspective of the patient. PROSPER comprises industry, regulatory authority, academic, private sector and patient representatives who are interested in the area of patient-reported outcomes of adverse events (PRO-AEs). It has developed guidance on PRO-AE data, including the benefits of wider use and approaches for data capture and analysis. Patient-reported outcomes (PROs) encompass the full range of self-reporting, rather than only patient reports collected by clinicians using validated instruments. In recent years, PROs have become increasingly important across the spectrum of healthcare and life sciences. Patient-centred models of care are integrating shared decision making and PROs at the point of care; comparative effectiveness research seeks to include patients as participatory stakeholders; and industry is expanding its involvement with patients and patient groups as part of the drug development process and safety monitoring. Additionally, recent pharmacovigilance legislation from regulatory authorities in the EU and the USA calls for the inclusion of patient-reported information in benefit-risk assessment of pharmaceutical products. For patients, technological advancements have made it easier to be an active participant in one's healthcare. Simplified internet search capabilities, electronic and personal health records, digital mobile devices, and PRO-enabled patient online communities are just a few examples of tools that allow patients to gain increased knowledge about conditions, symptoms, treatment options and side effects. Despite these changes and increased attention on the perceived value of PROs, their full potential has yet to be realised in pharmacovigilance. Current safety reporting and risk assessment processes remain heavily dependent on healthcare professionals, though there are known limitations such

  14. Factors associated with the patient safety climate at a teaching hospital1

    PubMed Central

    Luiz, Raíssa Bianca; Simões, Ana Lúcia de Assis; Barichello, Elizabeth; Barbosa, Maria Helena

    2015-01-01

    Objectives: to investigate the association between the scores of the patient safety climate and socio-demographic and professional variables. Methods: an observational, sectional and quantitative study, conducted at a large public teaching hospital. The Safety Attitudes Questionnaire was used, translated and validated for Brazil. Data analysis used the software Statistical Package for Social Sciences. In the bivariate analysis, we used Student's t-test, analysis of variance and Spearman's correlation of (α=0.05). To identify predictors for the safety climate scores, multiple linear regression was used, having the safety climate domain as the main outcome (α=0.01). Results: most participants were women, nursing staff, who worked in direct care to adult patients in critical areas, without a graduate degree and without any other employment. The average and median total score of the instrument corresponded to 61.8 (SD=13.7) and 63.3, respectively. The variable professional performance was found as a factor associated with the safety environment for the domain perception of service management and hospital management (p=0.01). Conclusion: the identification of factors associated with the safety environment permits the construction of strategies for safe practices in the hospitals. PMID:26487138

  15. Students' perceptions of patient safety during the transition from undergraduate to postgraduate training: an activity theory analysis.

    PubMed

    de Feijter, Jeantine M; de Grave, Willem S; Dornan, Tim; Koopmans, Richard P; Scherpbier, Albert J J A

    2011-08-01

    Evidence that medical error can cause harm to patients has raised the attention of the health care community towards patient safety and influenced how and what medical students learn about it. Patient safety is best taught when students are participating in clinical practice where they actually encounter patients at risk. This type of learning is referred to as workplace learning, a complex system in which various factors influence what is being learned and how. A theory that can highlight potential difficulties in this complex learning system about patient safety is activity theory. Thirty-four final year undergraduate medical students participated in four focus groups about their experiences concerning patient safety. Using activity theory as analytical framework, we performed constant comparative thematic analysis of the focus group transcripts to identify important themes. We found eight general themes relating to two activities: learning to be a doctor and delivering safe patient care. Simultaneous occurrence of these two activities can cause contradictions. Our results illustrate the complexity of learning about patient safety at the workplace. Students encounter contradictions when learning about patient safety, especially during a transitional phase of their training. These contradictions create potential learning opportunities which should be used in education about patient safety. Insight into the complexities of patient safety is essential to improve education in this important area of medicine.

  16. Safety Profile of Nivolumab Monotherapy: A Pooled Analysis of Patients With Advanced Melanoma.

    PubMed

    Weber, Jeffrey S; Hodi, F Stephen; Wolchok, Jedd D; Topalian, Suzanne L; Schadendorf, Dirk; Larkin, James; Sznol, Mario; Long, Georgina V; Li, Hewei; Waxman, Ian M; Jiang, Joel; Robert, Caroline

    2017-03-01

    Purpose We conducted a retrospective analysis to assess the safety profile of nivolumab monotherapy in patients with advanced melanoma and describe the management of adverse events (AEs) using established safety guidelines. Patients and Methods Safety data were pooled from four studies, including two phase III trials, with patients who received nivolumab 3 mg/kg once every 2 weeks. We evaluated rate of treatment-related AEs, time to onset and resolution of select AEs (those with potential immunologic etiology), and impact of select AEs and suppressive immune-modulating agents (IMs) on antitumor efficacy. Results Among 576 patients, 71% (95% CI, 67% to 75%) experienced any-grade treatment-related AEs (most commonly fatigue [25%], pruritus [17%], diarrhea [13%], and rash [13%]), and 10% (95% CI, 8% to 13%) experienced grade 3 to 4 treatment-related AEs. No drug-related deaths were reported. Select AEs (occurring in 49% of patients) were most frequently skin related, GI, endocrine, and hepatic; grade 3 to 4 select AEs occurred in 4% of patients. Median time to onset of select AEs ranged from 5 weeks for skin to 15 weeks for renal AEs. Approximately 24% of patients received systemic IMs to manage select AEs, which in most cases resolved. Adjusting for number of doses, objective response rate (ORR) was significantly higher in patients who experienced treatment-related select AEs of any grade compared with those who did not. ORRs were similar in patients who did and patients who did not receive systemic IMs. Conclusion Treatment-related AEs with nivolumab monotherapy were primarily low grade, and most resolved with established safety guidelines. Use of IMs did not affect ORR, although treatment-related select AEs of any grade were associated with higher ORR, but no progression-free survival benefit.

  17. Long-term Efficacy and Safety of Adalimumab in Pediatric Patients with Crohn's Disease

    PubMed Central

    Dubinsky, Marla; Ruemmele, Frank M.; Escher, Johanna; Rosh, Joel; Hyams, Jeffrey S.; Eichner, Samantha; Li, Yao; Reilly, Nattanan; Thakkar, Roopal B.; Robinson, Anne M.; Lazar, Andreas

    2017-01-01

    Background: IMAgINE 1 assessed 52-week efficacy and safety of adalimumab in children with moderate to severe Crohn's disease. Long-term efficacy and safety of adalimumab for patients who entered the IMAgINE 2 extension are reported. Methods: Patients who completed IMAgINE 1 could enroll in IMAgINE 2. Endpoints assessed from weeks 0 to 240 of IMAgINE 2 were Pediatric Crohn's Disease Activity Index remission (Pediatric Crohn's Disease Activity Index ≤ 10) and response (Pediatric Crohn's Disease Activity Index decrease ≥15 from IMAgINE 1 baseline) using observed analysis and hybrid nonresponder imputation (hNRI). For hNRI, discontinued patients were imputed as failures unless they transitioned to commercial adalimumab (with study site closure) or adult care, where last observation was carried forward. Corticosteroid-free remission in patients receiving corticosteroids at IMAgINE 1 baseline, discontinuation of immunomodulators (IMMs) in patients receiving IMMs at IMAgINE 2 baseline, and linear growth improvement were reported as observed. Adverse events were assessed for patients receiving ≥1 adalimumab dose in IMAgINE 1 and 2 through January 2015. Results: Of 100 patients enrolled in IMAgINE 2, 41% and 48% achieved remission and response (hNRI) at IMAgINE 2 week 240. Remission rates were maintained by 45% (30/67, hNRI) of patients who entered IMAgINE 2 in remission. At IMAgINE 2 week 240, 63% (12/19) of patients receiving corticosteroids at IMAgINE 1 baseline achieved corticosteroid-free remission and 30% (6/20) of patients receiving IMMs at IMAgINE 2 baseline discontinued IMMs. Adalimumab treatment led to growth velocity normalization. No new safety signals were identified. Conclusions: Efficacy and safety profiles of prolonged adalimumab treatment in children with Crohn's disease were consistent with IMAgINE 1 and adult Crohn's disease adalimumab trials. PMID:28129288

  18. Safety and efficacy of vena cava filters in trauma patients.

    PubMed

    Giannoudis, Peter V; Pountos, Ippokratis; Pape, Hans Christoph; Patel, Jai V

    2007-01-01

    Pulmonary embolism (PE), due to its sudden onset, notoriously difficult diagnosis, unpredictable nature and often fatal outcome, remains one of the most feared complications in surgical practice. Trauma patients with multisystem injuries, extremity or pelvic fractures and head or spinal cord injuries often pose a significant dilemma for the surgeon because of the inability to use conventional measures such as anticoagulation therapy and compression devices. On the other hand, the incidence of deep vein thrombosis (DVT) is high among trauma patients and the attendant risk of PE is an important cause of morbidity and mortality. Inferior vena cava (IVC) interruption by placement of diverse filtering devices has evolved over the past three decades. With the use of these devices, the risk of PE has been reduced dramatically. However, variable rates of complications are reported from their use. In this study, we review all the available data on IVC filter placement in trauma patients and we discuss the potential complications of IVC filters in order to understand better the risk/benefit ratio of their use.

  19. Temporal trends in safety of carotid endarterectomy in asymptomatic patients

    PubMed Central

    Munster, Alex B.; Franchini, Angelo J.; Qureshi, Mahim I.; Thapar, Ankur

    2015-01-01

    Objective: To systematically review temporal changes in perioperative safety of carotid endarterectomy (CEA) in asymptomatic individuals in trial and registry studies. Methods: The MEDLINE and EMBASE databases were searched using the terms “carotid” and “endarterectomy” and “asymptomatic” from 1947 to August 23, 2014. Articles dealing with 50%–99% stenosis in asymptomatic individuals were included and low-volume studies were excluded. The primary endpoint was 30-day stroke or death and the secondary endpoint was 30-day all-cause mortality. Statistical analysis was performed using random-effects meta-regression for registry data and for trial data graphical interpretation alone was used. Results: Six trials (n = 4,431 procedures) and 47 community registries (n = 204,622 procedures) reported data between 1983 and 2013. Registry data showed a significant decrease in postoperative stroke or death incidence over the period 1991–2010, equivalent to a 6% average proportional annual reduction (95% credible interval [CrI] 4%–7%; p < 0.001). Considering postoperative all-cause mortality, registry data showed a significant 5% average proportional annual reduction (95% CrI 3%–9%; p < 0.001). Trial data showed a similar visual trend. Conclusions: CEA is safer than ever before and high-volume registry results closely mirror the results of trials. New benchmarks for CEA are a stroke or death risk of 1.2% and a mortality risk of 0.4%. This information will prove useful for quality improvement programs, for health care funders, and for those re-examining the long-term benefits of asymptomatic revascularization in future trials. PMID:26115734

  20. Systematic biases in group decision-making: implications for patient safety.

    PubMed

    Mannion, Russell; Thompson, Carl

    2014-12-01

    Key decisions in modern health care systems are often made by groups of people rather than lone individuals. However, group decision-making can be imperfect and result in organizational and clinical errors which may harm patients-a fact highlighted graphically in recent (and historical) health scandals and inquiries such as the recent report by Sir Robert Francis into the serious failures in patient care and safety at Mid Staffordshire Hospitals NHS Trust in the English NHS. In this article, we draw on theories from organization studies and decision science to explore the ways in which patient safety may be undermined or threatened in health care contexts as a result of four systematic biases arising from group decision-making: 'groupthink', 'social loafing', 'group polarization' and 'escalation of commitment'. For each group bias, we describe its antecedents, illustrate how it can impair group decisions with regard to patient safety, outline a range of possible remedial organizational strategies that can be used to attenuate the potential for adverse consequences and look forward at the emerging research agenda in this important but hitherto neglected area of patient safety research.

  1. A broad and structured approach to improving patient safety and quality: lessons from Denver Health.

    PubMed

    Gabow, Patricia A; Mehler, Philip S

    2011-04-01

    America's health care systems have not achieved the desired level of quality and safety. This may be due, in part, to the lack of clear and robust approaches for institutions to follow. Denver Health, an integrated, public safety-net institution, developed a multifaceted, structured approach to quality and safety improvement that has produced positive outcomes. For example, in 2010 Denver Health ranked first of 112 US academic medical centers in terms of actual mortality observed relative to the national mortality rate. Given these results, we argue that regulatory bodies should refocus their oversight to consider an institution's overall structured approach to quality improvement and safety, instead of monitoring individual small outcomes, such as a patient's receipt of antibiotics for pneumonia within six hours of arriving in the emergency department.

  2. Addressing Medical Errors in Hand Surgery

    PubMed Central

    Johnson, Shepard P.; Adkinson, Joshua M.; Chung, Kevin C.

    2014-01-01

    Influential think-tank such as the Institute of Medicine has raised awareness about the implications of medical errors. In response, organizations, medical societies, and institutions have initiated programs to decrease the incidence and effects of these errors. Surgeons deal with the direct implications of adverse events involving patients. In addition to managing the physical consequences, they are confronted with ethical and social issues when caring for a harmed patient. Although there is considerable effort to implement system-wide changes, there is little guidance for hand surgeons on how to address medical errors. Admitting an error is difficult, but a transparent environment where patients are notified of errors and offered consolation and compensation is essential to maintain trust. Further, equipping hand surgeons with a guide for addressing medical errors will promote compassionate patient interaction, help identify system failures, provide learning points for safety improvement, and demonstrate a commitment to ethically responsible medical care. PMID:25154576

  3. Patient safety culture in primary care: developing a theoretical framework for practical use

    PubMed Central

    Kirk, Susan; Parker, Dianne; Claridge, Tanya; Esmail, Aneez; Marshall, Martin

    2007-01-01

    Objective Great importance has been attached to a culture of safe practice in healthcare organisations, but it has proved difficult to engage frontline staff with this complex concept. The present study aimed to develop and test a framework for making the concept of safety culture meaningful and accessible to managers and frontline staff, and facilitating discussion of ways to improve team/organisational safety culture. Setting Eight primary care trusts and a sample of their associated general practices in north west England. Methods In phase 1 a comprehensive review of the literature and a postal survey of experts helped identify the key dimensions of safety culture in primary care. Semistructured interviews with 30 clinicians and managers explored the application of these dimensions to an established theory of organisational maturity. In phase 2 the face validity and utility of the framework was assessed in 33 interviews and 14 focus groups. Results Nine dimensions were identified through which safety culture is expressed in primary care organisations. Organisational descriptions were developed for how these dimensions might be characterised at five levels of organisational maturity. The resulting framework conceptualises patient safety culture as multidimensional and dynamic, and seems to have a high level of face validity and utility within primary care. It aids clinicians' and managers' understanding of the concept of safety culture and promotes discussion within teams about their safety culture maturity. Conclusions The framework moves the agenda on from rhetoric about the importance of safety culture to a way of understanding why and how the shared values of staff working within a healthcare organisation may be operationalised to create a safe environment for patient care. PMID:17693682

  4. Creating an Oversight Infrastructure for Electronic Health Record-Related Patient Safety Hazards

    PubMed Central

    Singh, Hardeep; Classen, David C.; Sittig, Dean F.

    2013-01-01

    Electronic health records (EHRs) have potential quality and safety benefits. However, reports of EHR-related safety hazards are now emerging. The Office of the National Coordinator (ONC) for Health Information Technology (HIT) recently sponsored an Institute of Medicine committee to evaluate how HIT use affects patient safety. In this paper, we propose the creation of a national EHR oversight program to provide dedicated surveillance of EHR-related safety hazards and to promote learning from identified errors, close calls, and adverse events. The program calls for data gathering, investigation/analysis and regulatory components. The first two functions will depend on institution-level EHR safety committees that will investigate all known EHR-related adverse events and near-misses and report them nationally using standardized methods. These committees should also perform routine safety self-assessments to proactively identify new risks. Nationally, we propose the long-term creation of a centralized, non-partisan board with an appropriate legal and regulatory infrastructure to ensure the safety of EHRs. We discuss the rationale of the proposed oversight program and its potential organizational components and functions. These include mechanisms for robust data collection and analyses of all safety concerns using multiple methods that extend beyond reporting; multidisciplinary investigation of selected high-risk safety events; and enhanced coordination with other national agencies in order to facilitate broad dissemination of hazards information. Implementation of this proposed infrastructure can facilitate identification of EHR-related adverse events and errors and potentially create a safer and more effective EHR-based health care delivery system. PMID:22080284

  5. Toward improving patient safety through voluntary peer-to-peer assessment.

    PubMed

    Hudson, Daniel W; Holzmueller, Christine G; Pronovost, Peter J; Gianci, Sebastiana J; Pate, Zack T; Wahr, Joyce; Heitmiller, Eugenie S; Thompson, David A; Martinez, Elizabeth A; Marsteller, Jill A; Gurses, Ayse P; Lubomski, Lisa H; Goeschel, Christine A; Pham, Julius Cuong

    2012-01-01

    Health care has primarily used retrospective review approaches to identify and mitigate hazards, with little evidence of measurable and sustained improvements in patient safety. Conversely, the nuclear power industry has used a prospective peer-to-peer (P2P) assessment process grounded in open information exchange and cooperative organizational learning to realize substantial and sustainable improvements in safety. In comparing approaches, it is evident that health care's sluggish progress stems from weaknesses in hazard identification and mitigation and in organizational learning. This article proposes creating and implementing a structured prospective P2P assessment model in health care, similar to that used in the nuclear power industry, to accelerate improvements in patient safety.

  6. Safety and Effectiveness of Indacaterol in Chronic Obstructive Pulmonary Disease Patients in South Korea

    PubMed Central

    Yum, Ho-Kee; Kim, Hak-Ryul; Chang, Yoon Soo; Shin, Kyeong-Cheol; Kim, Song

    2017-01-01

    Background Inhaled indacaterol (Onbrez Breezhaler), a long-acting β2-agonist, is approved in over 100 countries, including South Korea, as a once-daily bronchodilator for maintenance and treatment of chronic obstructive pulmonary disease (COPD). Here, we present an interim analysis of a post-marketing surveillance study conducted to evaluate the real-world safety and effectiveness of indacaterol in the Korean population. Methods This was an open-label, observational, prospective study in which COPD patients, who were newly prescribed with indacaterol (150 or 300 µg), were evaluated for 12 or 24 weeks. Safety was assessed based on the incidence rates of adverse events (AEs) and serious adverse events (SAEs). Effectiveness was evaluated based on physician's assessment by considering changes in symptoms and lung function, if the values of forced expiratory volume in 1 second were available. Results Safety data were analyzed in 1,016 patients of the 1,043 enrolled COPD patients receiving indacaterol, and 784 patients were included for the effectiveness analysis. AEs were reported in 228 (22.44%) patients, while 98 (9.65%) patients reported SAEs. The COPD condition improved in 348 patients (44.4%), while the condition was maintained in 396 patients (50.5%), and only 40 patients (5.1%) exhibited worsening of ailment as compared with baseline. During the treatment period, 90 patients were hospitalized while nine patients died. All deaths were assessed to be not related to the study drug by the investigator. Conclusion In real-life clinical practice in South Korea, indacaterol was well tolerated in COPD patients, and can be regarded as an effective option for their maintenance treatment. PMID:28119747

  7. Confirming delivery: understanding the role of the hospitalized patient in medication administration safety.

    PubMed

    Macdonald, Marilyn T; Heilemann, MarySue V; MacKinnon, Neil J; Lang, Ariella; Gregory, David; Gurnham, Mary Ellen; Fillatre, Theresa

    2014-04-01

    The purpose of our study was to gain an understanding of current patient involvement in medication administration safety from the perspectives of both patients and nursing staff members. Administering medication is taken for granted and therefore suited to the development of theory to enhance its understanding. We conducted a constructivist, grounded theory study involving 24 patients and 26 nursing staff members and found that patients had the role of confirming delivery in the administration of medication. Confirming delivery was characterized by three interdependent subprocesses: engaging in the medication administration process, being "half out of it" (patient mental status), and perceiving time. We believe that ours is one of the first qualitative studies on the role of hospitalized patients in administering medication. Medication administration and nursing care systems, as well as patient mental status, impose limitations on patient involvement in safe medication administration.

  8. Patient safety: the landscape of the global research output and gender distribution

    PubMed Central

    Schreiber, Moritz; Klingelhöfer, Doris; Groneberg, David A; Brüggmann, Doerthe

    2016-01-01

    Objectives Patient safety is a crucial issue in medicine. Its main objective is to reduce the number of deaths and health damages that are caused by preventable medical errors. To achieve this, it needs better health systems that make mistakes less likely and their effects less detrimental without blaming health workers for failures. Until now, there is no in-depth scientometric analysis on this issue that encompasses the interval between 1963 and 2014. Therefore, the aim of this study is to sketch a landscape of the past global research output on patient safety including the gender distribution of the medical discipline of patient safety by interpreting scientometric parameters. Additionally, respective future trends are to be outlined. Setting The Core Collection of the scientific database Web of Science was searched for publications with the search term ‘Patient Safety’ as title word that was focused on the corresponding medical discipline. The resulting data set was analysed by using the methodology implemented by the platform NewQIS. To visualise the geographical landscape, state-of-the-art techniques including density-equalising map projections were applied. Results 4079 articles on patient safety were identified in the period from 1900 to 2014. Most articles were published in North America, the UK and Australia. In regard to the overall number of publications, the USA is the leading country, while the output ratio to the population of Switzerland was found to exhibit the best performance. With regard to the ratio of the number of publications to the Gross Domestic Product (GDP) per Capita, the USA remains the leading nation but countries like India and China with a low GDP and high population numbers are also profiting. Conclusions Though the topic is a global matter, the scientific output on patient safety is centred mainly in industrialised countries. PMID:26873042

  9. Patient Preferences for Biologicals in Psoriasis: Top Priority of Safety for Cardiovascular Patients.

    PubMed

    Schaarschmidt, Marthe-Lisa; Kromer, Christian; Herr, Raphael; Schmieder, Astrid; Sonntag, Diana; Goerdt, Sergij; Peitsch, Wiebke K

    2015-01-01

    Patients with psoriasis are often affected by comorbidities, which largely influence treatment decisions. Here we performed conjoint analysis to assess the impact of comorbidities on preferences of patients with moderate-to-severe psoriasis for outcome (probability of 50% and 90% improvement, time until response, sustainability of success, probability of mild and severe adverse events (AE), probability of ACR 20 response) and process attributes (treatment location, frequency, duration and delivery method) of biologicals. The influence of comorbidities on Relative Importance Scores (RIS) was determined with analysis of variance and multivariate regression. Among the 200 participants completing the study, 22.5% suffered from psoriatic arthritis, 31.5% from arterial hypertension, 15% from cardiovascular disease (myocardial infarction, stroke, coronary artery disease, and/or arterial occlusive disease), 14.5% from diabetes, 11% from hyperlipidemia, 26% from chronic bronchitis or asthma and 12.5% from depression. Participants with psoriatic arthritis attached greater importance to ACR 20 response (RIS = 10.3 vs. 5.0, p<0.001; β = 0.278, p<0.001) and sustainability (RIS = 5.8 vs. 5.0, p = 0.032) but less value to time until response (RIS = 3.4 vs. 4.8, p = 0.045) than those without arthritis. Participants with arterial hypertension were particularly interested in a low risk of mild AE (RIS 9.7 vs. 12.1; p = 0.033) and a short treatment duration (RIS = 8.0 vs. 9.6, p = 0.002). Those with cardiovascular disease worried more about mild AE (RIS = 12.8 vs. 10, p = 0.027; β = 0.170, p = 0.027) and severe AE (RIS = 23.2 vs. 16.2, p = 0.001; β = 0.203, p = 0.007) but cared less about time until response (β = -0.189, p = 0.013), treatment location (β = -0.153, p = 0.049), frequency (β = -0.20, p = 0.008) and delivery method (β = -0.175, p = 0.023) than others. Patients' concerns should be addressed in-depth when prescribing biologicals to comorbid patients, keeping in mind

  10. Using patient safety indicators to estimate the impact of potential adverse events on outcomes.

    PubMed

    Rivard, Peter E; Luther, Stephen L; Christiansen, Cindy L; Shibei Zhao; Loveland, Susan; Elixhauser, Anne; Romano, Patrick S; Rosen, Amy K

    2008-02-01

    The authors estimated the impact of potentially preventable patient safety events, identified by Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs), on patient outcomes: mortality, length of stay (LOS), and cost. The PSIs were applied to all acute inpatient hospitalizations at Veterans Health Administration (VA) facilities in fiscal 2001. Two methods-regression analysis and multivariable case matching- were used independently to control for patient and facility characteristics while predicting the effect of the PSI on each outcome. The authors found statistically significant (p < .0001) excess mortality, LOS, and cost in all groups with PSIs. The magnitude of the excess varied considerably across the PSIs. These VA findings are similar to those from a previously published study of nonfederal hospitals, despite differences between VA and non-VA systems. This study contributes to the literature measuring outcomes of medical errors and provides evidence that AHRQ PSIs may be useful indicators for comparison across delivery systems.

  11. Health information technology and its effects on hospital costs, outcomes, and patient safety.

    PubMed

    Encinosa, William E; Bae, Jaeyong

    Underlying many reforms in the Patient Protection and Affordable Care Act (ACA) is the use of electronic medical records (EMRs) to help contain costs. We use MarketScan claims data and American Hospital Association information technology (IT) data to examine whether EMRs can contain costs in the ACA's reforms to reduce patient safety events. We find EMRs do not reduce the rate of patient safety events. However, once an event occurs, EMRs reduce death by 34%, readmissions by 39%, and spending by $4,850 (16%), a cost offset of $1.75 per $1 spent on IT capital. Thus, EMRs contain costs by better coordinating care to rescue patients from medical errors once they occur.

  12. An examination of technical efficiency, quality, and patient safety in acute care nursing units.

    PubMed

    Mark, Barbara A; Jones, Cheryl Bland; Lindley, Lisa; Ozcan, Yasar A

    2009-08-01

    Using an innovative statistical approach-data envelopment analysis-the authors examined the technical efficiency of 226 medical, surgical, and medical-surgical nursing units in 118 randomly selected acute care hospitals. The authors used the inputs of registered nurse, licensed practical nurse, and unlicensed hours of care; operating expenses; and number of beds on the unit. Outputs included case mix adjusted discharges, patient satisfaction (as a quality measure), and the rates of medication errors and patient falls (as measures of patient safety). This study found that 60% of units were operating at less than full efficiency. Key areas for improvement included slight reductions in labor hours and large reductions in medication errors and falls. The study findings indicate the importance of improving patient safety as a mechanism to simultaneously improve nursing unit efficiency.

  13. [Hand hygiene--part of patient safety from Semmelweis to the present].

    PubMed

    Anttila, Veli-Jukka

    2014-01-01

    Hand disinfection is one of the most important part of patient safety. By adequate hand disinfection healthcare workers can prevent about 40 per cent of healthcare-associated infections and about 50 per cent of patients' MRSA contaminations in hospitals. Adherence to hand disinfection has been observed in an average of 40 per cent of patient contacts. One of the risk factors leading to poor adherence is the "doctor" status of a healthcare worker. Introduction of an alcohol-based hand rub close to the patient is one of the most significant factors for improved hand hygiene.

  14. Safety and feasibility of dobutamine stress echocardiography in patients with implantable cardioverter defibrillators.

    PubMed

    Elhendy, Abdou; Windle, John; Porter, Thomas R

    2003-08-15

    Coronary artery disease is the underlying etiology of left ventricular dysfunction and arrhythmias in most patients who receive implantable cardioverter defibrillators (ICDs). The aim of this study was to assess the safety and feasibility of dobutamine stress echocardiography (DSE) in patients with an ICD. DSE (dobutamine up to 50 microg/kg/min, atropine up to 2 mg) was performed in 87 patients with an ICD and known or suspected coronary artery disease. The ICD was inactivated before the stress test and reactivated after the study; no serious complications occurred. DSE is a safe and feasible method for evaluating myocardial ischemia in patients with an ICD.

  15. [Efficacy and safety of use of likoprofit in patients with chronic prostatitis and prostatic adenoma].

    PubMed

    Spivak, L G

    2013-01-01

    The article summarizes the results of the clinical trials on application of likoprofit in patients with a chronic prostatitis and prostate adenoma, which were conducted by the Russian urologists for the last 8 years. Application of likoprofit in patients after TURP contributes to significantly earlier and effective restoration of microcirculation, which decreases the risk of development of postoperative complications and accelerates rehabilitation of patients. Studies in which likoprofit was applied in patients with a chronic prostatitis and prostate adenoma, proved that likoprofit also has antiedematous effect, improves the urination act, improves ejaculate parameters, positively impacts on sexual function, and has a high safety profile.

  16. NCCN Biosimilars White Paper: regulatory, scientific, and patient safety perspectives.

    PubMed

    Zelenetz, Andrew D; Ahmed, Islah; Braud, Edward Louis; Cross, James D; Davenport-Ennis, Nancy; Dickinson, Barry D; Goldberg, Steven E; Gottlieb, Scott; Johnson, Philip E; Lyman, Gary H; Markus, Richard; Matulonis, Ursula A; Reinke, Denise; Li, Edward C; DeMartino, Jessica; Larsen, Jonathan K; Hoffman, James M

    2011-09-01

    Biologics are essential to oncology care. As patents for older biologics begin to expire, the United States is developing an abbreviated regulatory process for the approval of similar biologics (biosimilars), which raises important considerations for the safe and appropriate incorporation of biosimilars into clinical practice for patients with cancer. The potential for biosimilars to reduce the cost of biologics, which are often high-cost components of oncology care, was the impetus behind the Biologics Price Competition and Innovation Act of 2009, a part of the 2010 Affordable Care Act. In March 2011, NCCN assembled a work group consisting of thought leaders from NCCN Member Institutions and other organizations, to provide guidance regarding the challenges health care providers and other key stakeholders face in incorporating biosimilars in health care practice. The work group identified challenges surrounding biosimilars, including health care provider knowledge, substitution practices, pharmacovigilance, naming and product tracking, coverage and reimbursement, use in off-label settings, and data requirements for approval.

  17. Information technology may not be 'it' for patient safety. Processes outweigh computers in improving quality.

    PubMed

    Greene, Jan

    2006-02-01

    While there is no question that information technology (IT) is inextricably tied to the future of health care delivery, claims that it is the cure-all for patient safety may be overrated. The key to success is managing change in organizational processes.

  18. 78 FR 70561 - Patient Safety Organizations: Delisting for Cause for Leadership Triad

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-11-26

    ... Patient Safety Organizations: Delisting for Cause for Leadership Triad AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice of delisting. SUMMARY: AHRQ has delisted Leadership Triad....108(a)(3)(iii)(C), Leadership Triad stated that it did not meet the requirement that, within 24...

  19. 77 FR 26280 - Patient Safety Organizations: Voluntary Relinquishment From CareRise LLC

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-05-03

    ... Relinquishment From CareRise LLC AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice of Delisting. SUMMARY: AHRQ has accepted a notification of voluntary relinquishment from CareRise LLC... quality of health care delivery. HHS issued the Patient Safety and Quality Improvement Final Rule...

  20. 77 FR 42737 - Patient Safety Organizations: Delisting for Cause for The Steward Group PSO

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-20

    ... Cause for The Steward Group PSO AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice of delisting. SUMMARY: AHRQ has delisted The Steward Group PSO as a Patient Safety Organization... Steward Group PSO failed to respond to a Notice of Preliminary Finding of Deficiency sent by AHRQ...